June/ July 2010
Are you a?
Pain Sufferer Therapist Student
Personal Details
First Name Last Name
Address
Post Code
State
Country
Contact Information
Contact number at home
Email Address
Occupation Hours per day
Therapist Information
Qualifications and years of experience as a therapist
Other Information
Do you already own Steve's Self Treatment Program?
Yes No
Are you currently practising it?
Next of Kin
Relationship to you
Age Weight Height
Do you have any medical conditions we should be aware of?
Do you have any special needs we should be aware of?
Level of Fitness
Strong and Fit Not fit I feel Weak/fragile
Where in your body do you feel pain?
Where in your body do you feel tightness?
Please give a brief history of your pain and treatments.
Diet Information
Please give us an honest account of what you eat and drink below so we can get an idea of your body condition. Please note the diet over the past couple of years then if you have changed it recently note the new foods you eat in (brackets) after that. Foods should be from a typical day, not the occasional foods you eat.
Breakfast
Lunch
Dinner
Deserts
Snacks
Water consumed in a typical day
Is the water bottled? Yes No
Alcohol consumed in a typical day
Other drinks consumed in a typical day
Vitamins or Supplements consumed in a typical day
Medications you take
Bowel movements per day
Are you a smoker ? Yes No
Any other information you would like us to know
Would you like to bring someone along with you to share your room as a non participating attendee? Yes No (Someone will contact you about this if you choose to do so)