© 2003 by
Cell - Meddetox System Ltd
●
Health Education - Sales - Marketing Company
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www.cell-meddetox.com
27
Medical Client Questionnaire for Practitioners
Name:
………………………………………..
D.O.B.
…………………
Treatment No.
Address:
……………………………………..
Postcode:
……………………………………..
Tel:
Yes No
1. Do you wear a pacemaker or any other pulsed device?..................................................
2. Have you had an organ transplant?
3. Have you any form of epilepsy, or any other form of black-out or seizure?
.................................................................................................................................................
4. Have you any degree of haemophilia?..............................................................................
5. Have you severe oedema? .................................................................................................
6. Are you pregnant or lactating? .........................................................................................
The reason for our questions is to safeguard you. If you answer ‘yes’ to any of the ques-
tions, we advise you to consult with your doctor before commencement of treatment.
It is possible to have the treatment whilst on medication but we recommend you take
your medication after the treatment.
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Please tell us of any existing symptoms you think we should know about:
__________________________________________________________________________
Comments on treatment:
I am willing to accept this treatment.
Signed: Date: