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Root Cause Biomagnetic Therapy
Date______________Name___________________________________________
DOB_________________
Full Address________________________________________________________
Phone____________________Email____________________________________
How did you hear about Root Cause?_________________________________
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? ______
Do I have your permission to discuss your case with others on your health-care team? Yes/No
If yes, please sign here : _________________________________________