Complete the Consultation Questionnaire

Name*

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Age In Years (Main Person who will use the PEMF Device)*

1 - How did you find us?

2 - Are you trying to treat anything specific? Is there any medical information our doctors should know beforehand?*

3 - Please reference and copy the condition/s you have from the list below.*

ADHD
ALS
Anticoagulants
Anxiety
Arrhythmias
Back pain
Baker's Cyst
Breast implants
Burns
Cancer
Cardiomyopathy
Carpal tunnel syndrome
Cataracts
Chronic Fatigue Chronic Regional Pain Syndrome (CRPS)
Colitis
Concussion
Congestive heart failure
Crohn's Disease
Deep Vein Thrombosis (DVT)
Defibrillator
Dental implants
Depression
Diabetes
Diverticulitis
Ear disease
Ehlers-Danlos
Endometriosis
Enlarged Prostate
Enuresis
Erectile Dysfunction (ED)
Fracture/s - recent

Gall bladder disease
Glioblastoma (GBM)
Glaucoma
Gout
Fibromyalgia
Grave's Disease (hyperthyroidism)
Hashimoto's Disease (hypothyroidism)
Herniated disc and extrusion
Hiccups (severe)
Hypertension (High Blood Pressure)
Hypothyroidism
Immune Deficiency
Incontinence/Overactive Bladder (OAB)
Infertility
Irritable bowel sysndrome
Joint replacement
Kidney Disease
Kidney Stones
Leukemia
Lung cancer
Lung disease
Lyme Disease
Lymphoma (cancer)
Macular degeneration
Multiple myeloma
Multiple Sclerosis (MS)
Neuropathy - Diabetic
Neuropathy (Peripheral)
Osteoarthritis (arthritis) in hands & feet
Osteonecrosis
Osteoporosis/Osteopenia
Ovarian Cancer (w/chemical sensitivity)

Overactive Bladder (OA)
Pacemaker
Pain modulator
Pancreatitis
Parasites/Worms
Parkinson's
Pelvic pain sysndrome
Prostate (enlarged)
Prostate cancer
PRP- platelet rich plasma injection/s
Psoriasis
Restless leg syndrome
Rheumatoid Arthritis (RA)
Scar/s, painful
Sciatica
Scleroderma
Scoliosis
Seizures
Shoulder problems
Sinusitis
Sleep disturbance
Stem Cell Injection/s
Stents
Stroke
Tendinitis
Tinnitus
Toxicity - Mold/insecticide/metal
Traumatic Brain Injury (TBI)
Trigeminal/facial neuralgia
Urinary incontinence
Valve replacement/repair
Venous insufficiency

4 - Have you looked at the following resources on our website? Please click on each link or copy it into your search/address bar to view the page.

Yes
No

You will get more value out of your consultation with Dr. Pawluk, if you have looked at these links so please review them before your consultation if you have not already.

New to PEMF? Start here - Link: http://bit.ly/newtoPEMF
Intensity matters - Link: https://www.drpawluk.com/videos/intensity-matters-video/
Pain, Inflammation, Adenosine and PEMF Therapy - Link: https://www.drpawluk.com/blog/pemfs-and-adenosine/
Setting a healing timeline - Link: http://bit.ly/healingtimeline
PEMF: How they heal - Link: http://bit.ly/PEMFhowtheyheal
Selecting a PEMF system - Link: http://bit.ly/selectPEMF

5 - Have you researched any PEMF equipment or devices?*

Yes
No

What equipment have you researched?

6 - Do you own or have experience with any PEMF system or device?*

Yes
No

What system or device have you used/are you using?

How frequently are you using the system?

Once or more a day
Once or more a week
Occasionally, when needed
I am no longer using the system

7 - Is there a specific PEMF system from drpawluk.com that you were interested in learning more about?*

8 - What do you hope PEMFs can do for you?

9 -Do you have any additional questions for our doctors?

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