Current Weight
Current Height
Have you recently had any rapid weight gain or loss?
Yes No
General energy level (scale of 1-10, 10 being optimal)
Average hours of sleep per night:
Do you wake up feeling refreshed?
Yes No
Do you have difficulty falling asleep?
Yes No
Do you have insomnia?
Yes No
Have Depression or Anxiety?
Yes No
Do you feel extreme stress or pressure (general life, work) from day to day?
Yes No
Do you wake up at night to go to the bathroom?
Yes No
Can you fall back asleep easily?
Yes No
Number of times you wake up during an average night:
If you wake during the night, at what time or times do you awaken in the night?
Do you smoke presently?
Yes No
How long have you smoked?
Have you ever smoked?
Yes No
Do you drink alcohol?
Yes No
How often?
Do you drink coffee?
Yes No
How much per day?
Do you drink soda?
Yes No
How much per day?
How much water do you drink per day?
Are you a vegetarian?
Yes No
How long?
Do you eat animal proteins?
Yes No
How many meals do you eat per day on average?
Do you exercise regularly?
Yes No
Types of exercise:
Have you ever seen a nutritionist?
Yes No
Do you take any vitamin or supplemental products?
Yes No
Have you been diagnosed with cancer?
Yes No
Type:
Have you ever had any surgeries?
Yes No
Please select all that apply:
Bone Tumor Dental Cosmetic Muscular Cartilage Tendon Organ Eye Ear Implants Transplants Pacemakers Stints Shunts Joint replacements
Have you ever been hospitalized?
Yes No
How long?
When?
Car Accidents?
Yes No
Broken Bones?
Yes No
Sprains or Dislocations?
Yes No
Any Scars?
Yes No
Have you had excessive hair loss?
Yes No
Sudden tiredness/weakness?
Yes No
Time of day:
Fever/chills?
Yes No
Sweat easily or excessively for unknown reasons?
Yes No
Musculo-skeletal System - Please check any areas that apply
Low Back pain Mid-back pain Neck pain Arm Problems Leg Problems Joint pain or dysfunction Muscular pain or dysfunction Arthritis Difficulty walking Broken bones Leg problems Torn muscles Muscle strains Ligament sprains Cartilage dysfunction or tears Constant joint stiffness or ache
Nervous system
Numbness/tingling Dizziness or Vertigo Fainting Frequent Headaches or Migraines Frequent Muscle Twitching, ticks or spasms Loss of coordination Loss of balance
Nose and Sinuses
Nose Pain Frequent nose bleeds Difficulty breathing through nose Hay fever Allergies Frequent sinus infections Nose surgery or reconstruction
Mouth, Throat, Neck
Frequent sore throats Gum problems Grinding of teeth, TMJ, Clicking Jaw Dental crowns, bridges, mouth work Gland swelling Braces (current or history)
Respiratory System
Asthma Chronic/frequent coughing Pain on breathing Frequent shortness of breath
Cardiovascular System and Peripheral Vascular System
High blood pressure Heart murmurs Heart palpitations Irregular heart beat Varicose veins
Gastrointestinal System
Frequent Constipation Frequent diarrhea Abdominal pain Colitis, Crohn’s Disease, or Ulcers Frequent Nausea/vomiting Frequent heartburn Frequent indigestion or gas Frequent cramps
Reproductive System
Prostate issues or enlargements Fibroids, cysts, or endometriosis Frequent cramping Heavy flow during period Menopause or peri-menopausal symptoms C-section Prolapsed Irregular cycle Currently pregnant
If pregnant, list week:
Any additional information you would like to include:
If necessary, I allow Anne Sotelo to discuss with my health care provider the appropriateness of Manual Therapy and movement training for my general health and wellness and I understand that Manual Therapy or movement training is not a replacement for medical treatment or medical diagnosis. I release Anne Sotelo from any kind of claim or injury resulting from any act or omission during movement practice or Manual Therapy treatment. I understand that I am responsible for payment if I cancel with less than 24 hours notice.
Consultations are by appointment only. Appointments are approximately 90 minutes. Please come to the session as “fragrancy free” as possible.
Please fill out all forms as fully, accurately and honestly as possible. Small details are just as important as major issues in assessing the body systems. Mental, emotional and social aspects of your life all play a role in your overall health. Please mention any stress or discomfort that you experience during the session! Manual and Melt therapy should not cause pain.
All information is completely confidential. Thank you.
This is due at the session in full. Venmo, Paypay, Cash, credit cards or personal checks are acceptable.
Please do not eat any food if possible one hour prior to appointment. Life-sustaining medications and remedies may be taken. Please wear comfortable active wear to your Melt Method appointments. Please wear briefs (gentlemen), underwear and camisole or non-underwire or non-sports bra (ladies) for Manual Therapy/ Rolfing appointments. Drink at least 8oz. of water prior to session as well as stay very hydrated the day after sessions. It is best not to wear a watch, belts or jewelry for sessions, as I will ask you to take off any metal during sessions
