New Client Questionnaire

PEMF Cellular Exercise New Clients Questions / COVID Questionnaire

Please fill out the New Client Questionnaire below to the best of your abilities. Thank you.

First Name *

Last Name *

Phone *

Email *

Height *

Weight *

Current Age *

Date of Birth *

Address (Street, City, Zip) *

As a COVID safety measure, do you currently have a fever? *

Does anyone in your household currently have COVID? *

Have you been exposed to anyone who has COVID in the past 14 days? *

Occupation

List any diagnoses ever received by a physician

Previous surgeries and location

Previous bone breaks and location

Previous injury that required medical attention

Daily medications

Daily vitamins/ supplements

Daily activities

Allergies to medications

Allergies to food or other

Do you smoke? If so, how much/often?

Recreational drug use, if so what?

Alcohol consumption and how often

Specific areas of pain to address currently

Level of daily anxiety experienced *

Level of depression experienced daily *

Do you have any electrically implanted devices? *

Are you currently on anti-rejection medication? *

Can we text updates to the phone number you provided? *

How did you hear about us? *

Questionnaire Confirmation *

Yes, I confirm

The information I have supplied above is factual and correct to the best of my knowledge.

Contraindications For Use *

Yes, I understand the information and agree with the terms contained within this document. Yes, I agree that by typing my Full Name above and clicking on the “Submit” button below I am electronically signing this document.

DO NOT USE IF YOU are pregnant, suspect you might be, or have implanted electronic devices, are an organ recipient; or have active bleeding. This warning includes any implanted electronic devices including but not limited to: pacemakers, defibrillators, nerve stimulator or cochlear devices. The only absolute contraindication for use of a PEMF device /Frequency Specific Microcurrent is placing an active applicator over implanted electrical devices like pacemakers, cochlear implants, intrathecal pumps, etc., because the magnetic field can shut the device off.

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