History Form

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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

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History Form

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

History Form

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