Register for the Thailand Treatment and Training Conference

Are you a?Pain SuffererSLM Student/TherapistNON SLM Therapist

Personal Details

First Name

Last Name

Address

Post Code

State

Country

Contact number at home

Email Address

Occupation

Hours per day

Qualifications and years of experience as a therapist

Do you already own Steve's Self Treatment Program?YesNo

Are you currently practising it?YesNo

Next of Kin

First Name

Last Name

Relationship to you

Contact Information

Present Condition

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 FitnessStrong and FitNot FitWeak or 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

Dietary 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?YesNo

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?YesNo

Other information

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 (We'll contact later you for the details)No