Before completing the intake form below, please prepare your personal timeline. A timeline is a chronological listing of the significant physical and emotional events in your life — from pre-birth to the present.

Your practitioner will use this information to guide your treatment. Please review the guide below, then enter your timeline in the field provided at the end of the form.

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Guide to Develop a Timeline​

Please place all shocks in a chronological order starting from conception/birth, or from the present and working your way back in time. The following types of events should be considered as possible shocks or traumas:

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Physical:

Pre-birth: any drugs, alcohol, smoking or severe illnesses in mother (particularly of a viral nature); also consider any emotional shocks to mother during pregnancy or in mother/father at time of conception (see section on emotional traumas below); ultrasound or other invasive testing.
 

Birth: Mother had difficult labour; forceps used; use of anaesthetics on mother; late breathing or other possible oxygen deprivation, ultrasound, amniocentesis
 

Vaccinations: Dates, if possible of first vaccination of each kind received
 

Accidents: car accidents, falls, blows to the head, concussions, broken bones, animal bites
 

Surgical interventions: such as tonsils, appendix, adenoids, dental, abdominal (including Caesarean sections); circumcision, vasectomy, hysterectomy
 

Drug Use: antibiotics, anti-depressants, recreational drugs, etc.

Hormones: birth control pills, hormone replacement therapy, IVF, etc.

Severe Infections: such as Lyme disease, mononucleosis, Epstein-Barr, Guillain Barre, measles, chicken pox, mumps, TB, pneumonia, Scarlet Fever, etc.
 

Electrical Shocks: including medical treatment

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Mental/Emotional:
 

Traumas involving loss, abandonment, grief, betrayal (e.g., death, loss of trust, relationship break-ups, loss of independence, job loss)

Traumas involving great fear/anxiety, stress

Traumas involving anger and indignation/humiliation (particularly where the emotion was suppressed/"swallowed"), guilt (mostly that someone tries to put on you)

Feelings of envy or jealousy, or guilt that you put on yourself, self-blame, shame

Traumas involving abuse, whether mental, emotional or sexual

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Note: Some emotional traumas can involve a combination of emotions.

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Timeline Example:
 

• May 2009 – H1N1 vaccine

• March 2009 – regular flu vaccine

• October 2008 – Amoxycillin antibiotic for ear infection had with the flu

• April 2008 – parents got divorced – felt angry, violated

• November 2006 – Cortisone shots for pain from sprained ankle

• September 2004 – grandmother died, very traumatic for me – angry, sad

• July 2001 – suffered whiplash from a car accident

• April 1999 – antifungal drug for a yeast infection

• 1990-1995 – on meds for chronic migraine headaches

• 1987 – broke my leg skiing

• 1985 – dental work – had 3 mercury fillings and general anesthetic

• 1984 – MMR vaccine booster shot

• 1982 – baby brother was born – I was jealous and felt a sense of loss (of attention)

• 1980 – original MMR vaccine

• 1978 – DPTP/Hib vaccine 3 times, 2 months apart

• 1977 – birth with forceps delivery, C-section

• Pre-birth – mother had amniocentesis, very stressed during pregnancy, multiple ultrasounds, mother smoked during pregnancy, etc.