Client Form

Back in Balance, LLC

Tash Canine, Rolf Practitioner, LMT

1726 Allied Street Suite 2-A

Charlottesville, VA 22903



HEALTH HISTORY:  Please print, fill out and bring to first appointment.)


Name ___________________________________

Referred by: _______________________________

Address _________________________________ City _________________Zip ____

Phone (h) ______________________ (cell) _______________________ (w) ________

Email ___________________________________ Occupation ________________

D.O.B.  _________________

Have you ever had Structural Integration or massage therapy?  If yes, date of last treatment ___________________________

Number of hours you sleep? __________________

Current medications.  List ALL:  _____________________________________________________________________________

Are you taking supplements, vitamins?  If so, please list: _______________________________

Do you stretch, exercise, and or utilize posture therapy of any kind?  ____ If yes, what type and frequency? ______________________________________________________________________________

Do you have any of the following:

Muscle aches or headaches?  If yes, where? _________________________ Frequency and intensity of pain?  __________________________________________________________

Is the pain alleviated with movement or made worse?  _____________________________

Do you feel the pain in the joint or in the muscle?  ________________________________

Cancer?  ____

Osteoporosis or osteopenia?  ____

Athlete’s Foot?  ___

Contagious or infectious disease?  ________________________

Phlebitis?  ____

High blood pressure?  ____

Past surgery?  ___ Dates:  _________________________________________

Currently pregnant? _________________

Circulatory problems or cardiac problems?  _______

Any other health problem, please describe:

Please state your over arching goal, how often you plan to make appointments, and what you hope to accomplish through your sessions:



CANCELLATION/RESCHEDULE POLICY: We absolutely appreciate your business however due to the large amount of time that must be blocked out for each appointment, the full fee will be charged for appointments or cancellations with less than 48 hour notice. Please do not come in if you are ill.


Contract for Care: I certify that the above information is true and accurate to the best of my knowledge, and I agree to keep my appointments in a timely manner. I agree to pay for cancellations, reschedules, or no-shows with less than 48- hour notice.  I forever release all liability from Back In Balance, Nitasha Canine, and her associates.  I agree to keep the therapist informed of any changes that develop over the course of our therapeutic relationship.


Signature ________________________________________________ Date _______