Human Intake Form

Human Intake Form
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Contact Number*
Format: (000) 000-0000.
Email Address*
example@example.com
TextPhone CallEmail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you're filling out this form on behalf of a minor, their name is:

First NameLast Name
Health History

For Whom the PEMF or Red Light/Near Infrared Light Therapy is for.
Reason for wanting to try PEMF or RL/NIL Therapy?*
Briefly outline any past injuries or illnesses*
Are you experiencing pain or discomfort? If so, please describe where, and the sensations.
Rate your pain from 1 to 10, where 10 is excruciating/"take me to the hospital"

1

2

3

4

5

6

7

8

9

10

1 is Very Mild, 10 is Excruciating
YesNo
If yes, for what, and which drug(s)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNoI might be/I'm trying
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, what type
If you are in remission, for how long?
YesNo
My chemotherapy and/or radiation therapy treatments are scheduled to end: (date)
YesNo
YesNo
If yes, describe
YesNo
YesNo
If yes, describe
Availability - Please let me know your preference for days/dates/time of day and I'll do my best to accommodate. (Please note practitioner availability is currently weekends, with limited evenings.)
Legal

Please read the following carefully.
YesNo
YesNo
* Staying hydrated and eating well can help mitigate these effects by appropriately fuelling the body.
YesNo
* Red light/near infrared light therapy may be a suitable alternative if you have medically implanted devices or have had an organ transplant. The practitioner can discuss this option with you if your criteria in this form apply.
YesNo
YesNo
Legal Name (or name of parent/legal guardian)*

First NameLast Name
Signature
Should be Empty:

Human Intake Form

Health History

Legal