PEMF Therapy

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PEMF Initial Session Questionnaire

Please complete this form before your first PEMF therapy session

Personal Information

Full Name *

Gender *

Pain Areas

Select any areas where you are experiencing pain

Head/Neck

Shoulders

Arms

Upper Back

Lower Back

Chest

Abdomen

Hips

Legs

Feet

Medical Devices & Implants

I have a pacemaker *

Yes

I have a defibrillator *

Yes

I have and use hearing aids *

Yes

I have and use an insulin pump *

Yes

If yes, can it be removed?

Yes

I am pregnant *

Yes

I am breastfeeding *

Yes

I have had surgery resulting in the placement of metal implants *

Yes

If yes, where?

Health Conditions

I have high blood pressure *

Yes

I have low blood pressure *

Yes

I have a history of light-headedness, dizziness or fainting that has not been diagnosed by my PCP *

Yes

I have or have had cancer *

Yes

If yes, what was the diagnosis?

If you are in remission, how long have you been in remission?

Current Treatments

I am currently undergoing chemotherapy *

Yes

My chemotherapy treatments are scheduled to end

My last chemotherapy treatment ended

I have had an organ transplant *

Yes

I have a PCP (Primary Care Physician) *

Yes

List any other wellness or alternative therapies you are participating in

List any other medical conditions and/or surgeries

Consent & Agreement

Please read and initial the following, and sign below:

I consent to let my practitioner and MagSpa NYC use my photo for marketing and training purposes. *

I understand that this MagSpa NYC session is not a replacement for medical care and that no diagnosis will be made. *

I understand that if I have a pacemaker, defibrillator, am pregnant or have any implanted device with a battery that cannot be removed I do not qualify for MagSpa NYC sessions. *

Printed Name *

Date