New Client QuestionnairePEMF Cellular Exercise New Clients Questions / COVID QuestionnairePlease fill out the New Client Questionnaire below to the best of your abilities. Thank you.Please enable JavaScript in your browser to complete this form.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? *SelectYesNoDoes anyone in your household currently have COVID? *SelectYesNoHave you been exposed to anyone who has COVID in the past 14 days? *SelectYesNoOccupationList any diagnoses ever received by a physicianPrevious surgeries and location Previous bone breaks and locationPrevious injury that required medical attention Daily medicationsDaily vitamins/ supplementsDaily activitiesAllergies to medicationsAllergies to food or otherDo you smoke? If so, how much/often?Recreational drug use, if so what?Alcohol consumption and how oftenSpecific areas of pain to address currently Level of daily anxiety experienced *Select1 - Low2345678910 - HighLevel of depression experienced daily *Select1 - Low2345678910 - HighDo you have any electrically implanted devices? *SelectYesNoAre you currently on anti-rejection medication? *SelectYesNoCan we text updates to the phone number you provided? *SelectYesNoHow did you hear about us? *Questionnaire Confirmation *Yes, I confirmThe 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.CommentSubmit