For People

Name(required)

Do you have a heart pace maker or stints?(required)

Gender(required)

Age of person receiving treatment(required)

Email(required)

Phone(required)

Address(required)

Date and Time requesting treatment(required)

What type of pain are you experiencing?(required) Migraines

muscle pain

lower back pain

upper back pain

shoulder

neck

knee

wrist

carpal tunnel

elbow

ankle

feet

hips

other

How long have you been experiencing these symptoms? (required)

When was your last treatment & what type of treatment was it?

Have you had any surgeries? If yes, what type of surgery & how long ago?

Were you involved in any accidents? (sport related, auto, etc.) List type & how long ago.

Have you been diagnosed by your doctor, if so, what is the diagnosis?(required)

What treatments, if any, were given to help with these issues?(required)

List any medications currently administering; including prescription, non-prescription, over the counter, and dietary supplements. **PEMF treatments can make medications work more effectively, there for, please be aware of, & document any sudden changes with regards to medication effects. Please monitor & discuss any concerns with your family doctor. **(required)

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