First Name *

Last Name *

Email *

Phone *

Date of Birth *

Sex assigned at birth *

Male
Female

Home Address *

Mailing Address

If same as home address, type "same"

General Health History

Do you have any current or past medical conditions (e.g., diabetes, heart disease, neurological disorders)? *

Yes
No

If yes, please list all conditions *

Are you taking any medications, supplements, or treatments? *

Yes
No

If yes, list all medications, supplements, or treatments (include dosage and frequency)

Do you have any allergies (e.g., medications, materials, adhesives)? *

Yes
No

If yes, list all allergies

Do you have any implanted medical devices (e.g., pacemaker, defibrillator, spinal stimulator)? *

Yes
No

If yes, please describe

Are you currently pregnant or planning to become pregnant? *

Yes
No
Not Applicable

Clotting Disorders

Do you have any current or past blood clotting disorders (e.g., deep vein thrombosis, pulmonary embolism, clotting factor deficiencies)? *

Yes
No

If yes, list all clotting disorders and duration (e.g., when diagnosed, how long managed)

Pain and Wellness Assessment

What is your primary reason for seeking the Senergy BioModulator? (Select all that apply) *

Pain Management
Stress Relief
Energy Enhancement
Other

If other, please describe

If seeking for pain management, describe the location(s) of your pain (e.g., lower back, shoulder, knee)

If applicable, is your pain acute (sudden, short-term), chronic (ongoing, 3+ months), both, or neither? *

Acute
Chronic
Both
Neither
Not Applicable

If applicable, rate your pain severity on a scale of 0 (no pain) to 10 (severe pain) * *

Select a number (0-10) or write "N/A" if Not Applicable

If applicable, how long have you experienced this pain? (e.g., weeks, months, years) *

Write 'N/A' if not seeking for pain management

If applicable, what triggers or worsens your pain? (e.g., activity, stress, weather) *

Write 'N/A' if not seeking for pain management

List any previous treatments for pain or wellness goals *

Write 'N/A' or "None" if you have not tried another treatment

Describe your wellness goals for using the Senergy BioModulator *

Consent and Verification

Informed Consent *

I understand that this form is part of a telehealth evaluation for a Senergy BioModulator prescription. I consent to the use of asynchronous telehealth, acknowledge its limitations (e.g., no real-time interaction), and agree to the sharing of my health information with licensed providers for this purpose.

Check to agree

Data Accuracy *

I confirm that all information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that providing false information may affect the appropriateness of the prescription.

Check to agree

Additional Information

Provide any other relevant details or questions for the provider

*Disclaimer: No medical claims are made regarding the use or effectiveness of Senergy’s BioModulator. This product is not intended to diagnose, treat, cure, or prevent any disease. Consult a qualified medical professional for medical advice. Your information is protected under HIPAA regulations and will only be shared with licensed providers for the purpose of this evaluation.

Senergy Wellness BioModulator® Prescription Form

General Health History

Clotting Disorders

Pain and Wellness Assessment

Consent and Verification

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