New Patients Start Here

Name *

First Name

Last Name

Phone *

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###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

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DD

YYYY

Osteoperosis *

No

Yes

Cancer *

No

Yes

Heart Problems or Hypertension *

No

Yes

Angina or Chest Pain *

No

Yes

Asthma *

No

Yes

Diabetes *

No

Yes

Lung Problems *

No

Yes

Anemia *

No

Yes

Hepatitis, HIV, or other bloodborne disease *

No

Yes

Metal Allergies *

No

Yes

Kidney Disease *

No

Yes

Stroke *

No

Yes

Seizures, Epilepsy, or Fainting *

No

Yes

Currently Pregnant

No

Yes

Have a pacemaker

No

Yes

Unexplained Weight Loss *

No

Yes

Poor Balance or Frequent Falls / Dizziness *

No

Yes

Bowel or Bladder Dysfunction *

No

Yes

Difficulty Swallowing *

No

Yes

Shortness of Breath *

No

Yes

Please enter today's date below: *

MM

DD

YYYY