Send $50. check to
Suzy Balliett, PO Box 394, Lyons CO 80540
Please cut & paste this questionnaire into your e-mail program. Then answer & return with any other information.
What is your chief complaint?
Do you have a medical diagnosis? If so, what & when?
Are you on any medications? If so, what are they?
Have you recently been injured?
What has helped your problem in the past?
What is your exposure level to electromagnetic fields?
Does your sleeping environment have electromagnetic fields?
How stressful is your life?
How do you reduce stress?
Describe your pain.... 0 to 10
throbbing / shooting / stabbing / sharp / cramping / gnawing
hot / aching / heavy / tender / splitting / exhausting
sickening / fearful / punishing / mild / moderate / severe
annoying / troublesome / miserable / intense / unbearable
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