1. Health Questionnaire
Do You Have A Pacemaker? Are You Pregnant? Do You Have Diabetes?
Yes No Yes No Yes No
Do You Have Any Other Heath Conditions (Implants, Surgeries)? No Yes, Please Explain
Do You Have? Bladder trouble Constipation Difficult breathing
Low Back Problems Excessive urination Black stool Persistent cough
Scanty/little urination Bloody stool Coughing phlegm
Pain between shoulders
Painful urination Hemorrhoids Coughing blood
Neck problems
Discolored urination
