This document is a personal history form for a structural integration client. It collects contact information, physical details, medical history including injuries, surgeries, treatments and medications, physical discomforts, activities and goals for structural integration sessions. For women, it asks if they are pregnant or have an IUD, and screens for menstrual difficulties or other relevant information. The form is confidential and collects information necessary for the structural integration practitioner to safely and effectively provide treatment.

1. GUILD FOR STRUCTURAL INTEGRATION, INC.
PERSONAL HISTORY FORM (CONFIDENTIAL)
NAME_________________________________________________________________________________
ADDRESS_____________________________________________________________________________
CITY/STATE/ZIP________________________________________________________________________
HOME PHONE____________________________ WORK PHONE_______________________________
D.O.B.______________________ HEIGHT__________ WEIGHT_____________ AGE_______________
OCCUPATION_______________________ FINANCIAL AGREEMENT____________________________
______________________________________________________________________________________
REFFERED BY:
NAME________________________________________________________________________________
ADDRESS_____________________________________________________________________________
PHONE_______________________________________________________________________________
YOUR GENERAL PHYSICAL STATE AT PRESENT_________________________________________
_____________________________________________________________________________________
MAJOR PHYSICAL INJURIES/DISABILITES________________________________________________
_____________________________________________________________________________________
HISTORY AND DATES OF OPERATIONS_________________________________________________
_____________________________________________________________________________________
ARE YOU PRESENTLY UNDER MEDICAL TREATMENT/MEDICATION/CHRONIC ILLNESS
(ALLERGIES, DIABETES, ETC.)___________________________________________________________
_____________________________________________________________________________________
IN THERAPY (PAST OR PRESENT)______________________________________________________
_____________________________________________________________________________________
PHYSICAL DISCOMFORTS (BE SPECIFIC)_________________________________________________
_____________________________________________________________________________________
SPORTS/PHYSICAL ACTIVITIES/INTERESTS_______________________________________________
_____________________________________________________________________________________
WHAT ARE YOUR GOALS FOR THE SI WORK___________________________________________
_____________________________________________________________________________________
IS THERE ANYTHING RELEVANT TO YOUR SI WORK THAT IS NOT COVERED THUS FAR?
PLEASE DESCRIBE HERE:_____________________________________________________________
_____________________________________________________________________________________
FOR WOMEN: ARE YOU PREGNANT?_______________ DO YOU HAVE AN IUD?_____________
DIFFICULTY DURING MENSTRUATION/ANY OTHER PERTINENT INFORMATION?______________
_____________________________________________________________________________________
P.O. BOX 1559, BOULDER, CO 80306 (303) 447-0122 (800) 447-0150