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
How would you like to be contacted?
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
Are you currently taking any medication?
If yes, for what, and which drug(s)
I have a pacemaker, defibrillator, cochlear implant, and/or an implanted medical device that cannot be removed.
I have a stent
I have and use removable hearing aids
I have and use an insulin pump
If yes, can it be removed?
I am pregnant
I have high blood pressure
If yes, I am taking medication for it
I have low blood pressure
If yes, I am taking medication for it
I have a history of light-headedness, fainting, or dizziness that has not been diagnosed by my healthcare provider
I have or have had cancer
If yes, what type
If you are in remission, for how long?
I am currently undergoing chemotherapy or radiation therapy
My chemotherapy and/or radiation therapy treatments are scheduled to end: (date)
I have had an organ transplant
I have had surgery resulting in the placement of metal implants
If yes, describe
I have a blood clot
I have had a head injury within 30 days
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.
I understand that PEMF therapy is not a replacement for medical care and no diagnoses will be made.
I understand that I may feel drowsy/tired/run down for one or more days following a PEMF therapy session and that this is a normal reaction.
* Staying hydrated and eating well can help mitigate these effects by appropriately fuelling the body.
I understand that if I have a pacemaker, am pregnant, had an organ transplant, or have any kind of implanted device with a battery that cannot to removed I do not qualify for PEMF therapy. (Light/Laser therapy *may be an alternative)
* 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.
I understand that fees owing must be paid within 30 days of services being performed or I will be subject to an interest of 10% added and compounded monthly.
(Optional) I consent to letting MearaPulse Therapies use my photos for marketing or training purposes.
Legal Name (or name of parent/legal guardian)

First NameLast Name
Signature
Should be Empty:

Human Intake Form

Health History

Legal