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Garden Health
Group

About
- Mission & Values
- Rolfing & Bodywork
Team
Contact Us
Home
Careers
Book Online

Welcome to Garden Health Group. We are experienced therapists to help people address issues that include anxiety and depression, OCD, marital issues, grief, somatic issues, trauma around giving birth, parenting, PTSD, women's issues, transitions, relational issues and more. Let us help you find your way through this trying time now and in the future.

About
- Mission & Values
- Rolfing & Bodywork
Team
Contact Us
Home
Careers
Book Online

Welcome to Garden Health Group. We are experienced therapists to help people address issues that include anxiety and depression, OCD, marital issues, grief, somatic issues, trauma around giving birth, parenting, PTSD, women's issues, transitions, relational issues and more. Let us help you find your way through this trying time now and in the future.

About
- Mission & Values
- Rolfing & Bodywork
Team
Contact Us
Home
Careers
Book Online

see you soon

Medical and Health form for clients who have booked Rolfing or massage. Please do NOT fill out more than once.

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Address*

Occupation*

Please share what brings you to Rolfing or massage and what you hope to achieve through this work together?*

Are you taking any medications? If so, please list them here.*

Emergency Contact name, relationship and phone number*

Please list any allergies topically or internally. (please write NA if Not Applicable)*

Are you pregnant?*

Yes

No

If necessary, have you been cleared by a physician for Rolfing or bodywork? (Pregnancy or other conditions may require an approval form from your health care provider.)

Yes

No

Are you receiving any medical interventions (for example physcial therapy or occupational therapy etc.)?

Yes

No

Please check any of the following boxes if you are experiencing the symptoms presently. Please include any specifics here if not listed.

Areas of swelling

Autoimmune disorder

Back issues

Neck issues

Bleeding disorders

Bruise easily

Bursitis

Cancer survivor

Cancer

Contagious condition

Decreased sensation

Diabetes

Fibromyalgia

Headaches or Migraines

Heart Condition

Congestive Heart Failure

Hypertension

Kidney disease

Multiple Sclerosis

Neurological condition

Neuropathy

Osteoarthritis

Osteoporosis

Phlebitis

Sciatica

Stroke

Tendonitis

TMJ disorder

Varicose veins

Vertigo/dizziness

Plantar fasciitis

Respiratory issues

Epilepsy or convulsions

Blood pressure high or low

Joint replacement

Yes

No

If yes to joint replacement(s), which joint(s) and when?

Any medical procedures in the past two year? Please respond NA if not applicable.*

Please describe any other medical or health conditions or injuries if not listed.*

Have you experienced massage before?*

Yes

No

Have you experienced Rolfing before?*

Yes

No

Reason for seeking massage*

Pain relief

Increased mobility

Specific issue

Other

Pressure I prefer is*

Firm

Deep

Light

Garden Health Group takes your health and safety and the health and safety of our therapists very seriously. All practitioners at GHG undergo sexual harassment training mandated by law in Illinois. Massage/Rolfing sessions will be terminated in the event of inappropriate conduct of any kind. This includes harassment, threatening speech or behavior, sexual advances or requests, or disrespectful actions or language. I understand and agree to this policy.

I give permission for the therapist to touch me. I agree that I will notify the therapist immediately if I have any issue with touch or how we are working together.

I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment.

A session will not occur if the client is under the influence of drugs or alcohol. The session fee will be paid as if a late cancellation. I understand and agree to this policy.

By signing this form, I acknowledge that I am aware of the benefits and risks of massage therapy/Rolfing. I have completed this form to the best of my knowledge & agree to inform my therapist of any medical changes now or in the future.*

Sign in the box or use the keyboard to type.

Signature field is empty.

Garden Health Group

414 Clinton Place, Suite 106

River Forest, IL 60305

708.866.6766

info@GardenHealthGroup.com

Close proximity to Lake/Harlem El stop. Behind DSW, next to Whole Foods, Walgreens, J.Crew, and Panera. Minutes from downtown Oak Park.

Wide variety of public transit available nearby to

Chicago, Oak Park, Forest Park, and more.

About
- Mission & Values
- Rolfing & Bodywork
Team
Contact Us
Home
Careers
Book Online

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