CANDIDATE PAST HISTORY TRAUMA FORM

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 NameLast Name
Date of Birth

MonthDayYear
E-mail
Marital Status
Gender
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

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?
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.
Should be Empty: