Eligibility Assessment

1

Have you had Red Light Therapy before?* This field is required.

Yes

No

Not Sure

2

Have you been referred to us by a physician?* This field is required.

Yes

No

3

Do you have cancer, a pacemaker or are you currently pregnant?* This field is required.

YESNO

4

Do you have an autoimmune disorder or chronic illness?

YESNO

5

Please list or explain your autoimmune disorder(s) and/or chronic illness.* This field is required.

6

Do you have any of the following conditions? Check all that apply:* This field is required.

Recent Surgeries (fewer than 2 weeks ago)

Liver or Kidney Disease

Epilepsy/Seizures

hypomelanism (albinism)

Chronic Migraines

None

7

Health Conditions - Outcome

8

Pregnancy/Cancer/Pacemaker Outcome

10

What are your reasons/goals for wanting to undergo Red Light Therapy?* This field is required.You may check multiple options

Weight Management

Pain & Inflammation Relief

Skin Health

Relaxation/Stress Relief

Holistic Wellness

Increased Energy

Disease or Illness

Other

11

What specifically do you hope to achieve with Red Light Therapy?* This field is required.Example: "Improve sleep" or "Reduce back pain"

12

On a scale of 1 to 10, how motivated are you to achieve these goals?* This field is required.1 being very little motivation, 10 being very high motivation

1 = not motivated & 10 = very highly motivated

13

Please use this space to ask any other questions that are not covered in this form?

Please enter your question here

14

We may have additional questions following our review of your assessment. Please provide your contact info so we can follow up with your results.* This field is required.

First Name

Last Name

15

Email Address* This field is required.

example@example.com

16

Contact Number* This field is required.