Appointment Type Lyme Disease SymptomsOther Symptoms
First Name
Last Name
Street Address
City
State
Zipcode
Best Phone Number to Reach You
Your Email
Your Date of Birth
Your Age
How did you hear about me?
Appointment Date: If you need a specific day of the week or time, please let me know and I will do my best to accommodate it. We may have to push it out an extra week or two to do so. I will give you the options of my earliest availability as well your request.
What health issues do you hope to address with Biomagnetism Therapy?
Tell me about any previous health issues you've had. Please be comprehensive - include allergies, operations, medical treatments, etc...
Are you taking any prescription medications? If yes, please list all of them
Are you taking any nutritional supplements and/or vitamins? If yes, please list all of them
Have you had any blood transfusions or organ transplants? YesNo
Have you had Chemotherapy or Radiation in the last 13 years? YesNo
Are you scheduled to receive Chemotherapy or Radiation in the next 12 months? YesNo
Do you have a Pacemaker? YesNo
Are you or could you be pregnant? YesNo
Are there any other concerns you think are important to your treatment?
