Forms | Root Cause BMT

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Root Cause Biomagnetic Therapy

Date______________Name___________________________________________

DOB_________________

Full Address________________________________________________________

Phone____________________Email____________________________________

How did you hear about Root Cause?_________________________________

List any diagnosis and/or current medical treatments you are undergoing (for Lyme, or other illness disorder):

How long have you been feeling unwell?

List any prescription medications you currently take:

Any previous health issues or surgeries I should know about?

Have you had chemotherapy or radiation in the last 13 years? Yes/No

Are you scheduled to receive chemo or radiation in the next 12 months? Yes/No

Are you, or could you be pregnant? Yes/No

Have you had the HPV vaccine? Yes/No

Have you had the Covid vaccine? Yes/No

If yes, how many have you had? ______

List any healing approaches that have been helpful to you. Please also list any that have not been helpful:

Are there any other concerns you think are important to your treatment?

Do I have your permission to discuss your case with others on your health-care team? Yes/No

If yes, please sign here : _________________________________________

and list the practitioners I have permission to communicate with below: