CONTACT US

Cir-Q-care Centre, Delhi
Padma Centre,
F-7B, Okhla Industrial Area (Phase I)
New Delhi
Ph: 011-65378220/21
Email: info@cirqcare.com

 

Do I Need PEMF Therapy?

 
Name :
     
Address :
     
Email  
     
Phone : , ,
     
Date of birth :
     
Occupation :
     
Name of your GP :
     
Medical History (Surgery , Diabetes, Hypertension, etc.)
 
I receive these medications and dietary supplements regularly:
 

INFORMATION FORM

Pain in

Leg Calf Thigh
Knee Hands Arms
Shoulder Neck Back
Loin Breast Joint

Pain when walking

Before 50 m Before 500 m

Prickling sensation in feet Burning sensation in feet Restless legs
Heavy legs Weary legs Cold legs
Cold feet    

Cramp in legs

Walking Resting At night

Swollen legs (oedema)

Permanent At night

Numbness in foot sole/toes

Like walking on a pillow

Varicose Veins

Infection Pain

Discolouring skin/spiders on legs

Ulcer, which do not heal on:

Feet/toes Legs

Swollen fingers Cold hands Prickling sensation I fingers

Eczema

Psoriasis Allergic

Neuritis Experience often infections Regularly indigestion
Experience often cystitis    

Regularly headache

Muscle tension Migraine

Diabetes

Type I Type II

Smoker

Former smoker

Allergic to specific type of medicine

Family history of Cardiac disorder

Other/ Comments

 
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