Confidential Health Record

Confidential Health Record

To assess your suitability for treatment, please fill in this form to the best of your ability.
Full Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Mobile number

Area CodePhone Number
E-mail*
example@example.com
Birth Trauma

PrematureBirth required assistance (forceps, vontoux)Other
Injury History
(Concussion, head trauma, falls, sports injuries, fractures, sprains, work related incidents)
Personal Medical Details

Please check and describe
Any specific health conditions or regular medication

Insertions (pins, plates, prostheses, stints, lenses etc)Major Surgery/OperationsBroken bonesMajor accidents or falls or physical traumaOther
Any current health conditions*
Please describe your symptoms, when it began and what you think the condition is related to (if none, please write 'none').
Systems Review

Please tick if you currently have any of the following conditions...
Cardiovascular Conditions

High blood pressureLow blood pressurePalpitationsChest painCirculation problemsVaricose veinsOther
Respiratory Conditions

SmokerSinusCatarrhChronic coughBreathing difficultyAsthmaOther
Glandular

ThyroidDiabetesType option 3Type option 4Other
Genito-Urinary

IncontinenceStress incontinenceFrequencyPainBloodProstateKidney/UTIOther
Nervous System

Sense of smellSense of tasteSightHearingTouchMuscular tremorCrampEpilepsyOther
Skin

EzcemaSkin eruptionAthletes footPsoriasisOther
Consent to Participation in the Practical Seminar.

Practical sessions are a large part of our seminars, in order to learn and become proficient in all ABC™ corrections you will be treating and be treated by the other seminar attendees.
I consent to the ABC™ correction practical seminar*

YesNo
Signature*

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Consent to the use of photographs taken during the seminar for social media and promotional materials for our future seminars.*

YesNo, sorryYes provided my face is hidden.
Under the Data Protection Act 2018 your data will be securely and confidentially stored by ABC™ Training Europe. Please sign below for your consent to the storage of your data.
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Confidential Health Record

Personal Medical Details

Systems Review

Consent to Participation in the Practical Seminar.