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 *

Prefix First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Date of Birth

Month Day Year
Date Date Picker Icon
Phone Number *

Area Code Phone Number
Mobile number

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

Premature Birth required assistance (forceps, vontoux)
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/Operations Broken bones Major accidents or falls or physical trauma
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 pressure Low blood pressure Palpitations Chest pain Circulation problems Varicose veins
Respiratory Conditions

Smoker Sinus Catarrh Chronic cough Breathing difficulty Asthma
Glandular

Thyroid Diabetes Type option 3 Type option 4
Genito-Urinary

Incontinence Stress incontinence Frequency Pain Blood Prostate Kidney/UTI
Nervous System

Sense of smell Sense of taste Sight Hearing Touch Muscular tremor Cramp Epilepsy
Skin

Ezcema Skin eruption Athletes foot Psoriasis
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 *

Yes No
Signature *

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

Yes No, sorry Yes 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.
Signature *

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Confidential Health Record

Personal Medical Details

Systems Review

Consent to Participation in the Practical Seminar.