EMSELLA New Patient Intake Form

Patient contact information

First Name *

Last Name *

My Pronouns

Date of Birth *

How did you hear about the EMSELLA chair and Pure Pelvic Health?

Street Address 1 *

Street Address 2

City *

Province

Postal Code *

Email *

Phone Number (please use format 000-000-0000) *

Emergency contact

Emergency Contact Phone Number (please use format 000-000-0000) *

Emergency Contact Name *

Family physician

Family Physician First Name

Family Physician Last Name

Insurance information

Health history

What are your goals and desired outcome with EMSELLA treatment? *

How long have you had the issue you would like to improve?

What else have you tried to improve your symptoms?

Do you currently use incontinence products such as pads or undergarments?

Yes

No

If you are currently using incontinence products such as pads or undergarments please let us know what products you are using? How many pads, undergarments, etc. per day do you use?

How many times do you void (pee) each day?

How many times do you wake to void (pee) each night?

Please describe your daily fluid intake. What do you drink each day? How much do you drink each day? When do you drink?

Do you drink any of the following on a regular basis?

Water

Coffee / Tea

Pop or other carbonated beverages

Alcoholic beverages

Is there anything else you would like us to know prior to your first appointment?

Contraindications to EMSELLA treatment

EMSELLA is amazing, but it is not for everyone. Contraindications to treatment include but are not limited to:

Cardiac Pacemakers
Implanted Defibrillators
Other Electronic Implants
Pulmonary Insufficiency
Metal Implants
Drug Pumps
Malignant Tumor
Pregnancy

We will review the contraindications to with you again prior to commencing treatment. For more information about contraindications to EMSELLA treatment please contact Pure Pelvic Health.

Thank you for submitting the EMSELLA New Patient Intake. It has been sent successfully. We look forward to seeing you soon!

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