CANDIDATE PAST HISTORY TRAUMA FORM
Please fill in the form below. This information will help us paint a picture of your current health situation before we start Finding the Primary.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date Picker Icon
E-mail
Marital Status
Single
Married
Divorced
Partner
Gender
Male
Female
Other
How did you hear about Finding The Primary?
What is your background as a practitioner? Please tell us for how long you have been in this field
Where did you study?
Tell us what you like to do to stay active, sports/hobbies, etc
Number of times/week
Do you have any children? State their names & their ages!
In your own words, please outline where you feel your current health is at overall
Please tick if you have had any of the following symptoms
Low back pain
Mid back pain
Neck pain
Shoulder pain
Elbow pain
Hand/wrist pain
Hip pain
Knee pain
Ankle/foot pain
Dizziness
Tinnitus
Vertigo
Headaches
Ear Infections
Asthma
Sleep problems
Sinus problems
Pins & Needles
Epilepsy
Tumous
Heartburn
Indigestion
Bloating
IBS
Diabetes ( 1/2)
High Blood Press
Chronic Fatigue
Kidney/Liver Iss
CV (heart) Issues
Thyroid issues
Anxiety
Depression
Autism
Phobias
Panic Attacks
Palpitations
ADHD
OCD
Mental Health Issues
Other
Please outline any ongoing health issues that you or other practitioners have not been able to fully resolve, either currently or in the past.
Please list any stuck patterns, or repeating functional indicators that you are aware of, that seem to reoccur in your body or your posture, often when you get checked by a practitioner...
This could be same short leg, same C1 fixation, same side HA, etc
Please list any medications you are currently taking
Please list any SUPPLEMENTS you are currently taking
Do you have any metal either IN your body, or attached to your body?
Piercings, plates, screws, metal fillings
Have you ever suffered any physical trauma in your lifetime? E.g. road traffic accidents, concussions, broken bones, etc.
Please list in chronological order with dates
Have you ever had any surgeries in your lifetime?
YES
NO
If you answered yes, please list your surgeries and include the date (s)
Please list any x-rays, scans, or investigations you have had in your lifetime
include the dates
Please list anything else (NOT PHYSICAL) that you feel has had a significant negative impact on your life.
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