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Are you under medical treatment for any medical condition at this time? Yes / No
Are you taking medications? Yes / No
Do you suffer from respiratory problems? Yes / No
Do you have epilepsy? Yes / No
Do you have any metal objects in your body? Yes / No
Do you have an implanted electronic device in your body? Yes / No
Do you have circulatory problems in your legs or arms? Yes / No
Do you have a heart condition? Yes / No
Did you have an operation in the last three years? Yes / No
Do you have diabetes or another metabolic illness? Yes / No
Do you have varicose veins? Yes / No
Do you have an open leg ulcer? Yes / No
Do you currently have, or have you ever had in the past a thrombosis? Yes / No
Do you have a known or suspected deep thrombosis or thrombophlebitis? Yes / No
Do you have dermatitis, infected wounds, gangrene, severe skin inflammation, or recent skin grafts? Yes / No
Do you have pain or numbness in any of your limbs? Yes / No
Do you have arteriosclerosis or other ischemic vascular diseases? Yes / No
Do you have unbalanced cardiac insufficiency? Yes / No
Are you pregnant? Yes / No
Contraindications:
Any pain or numbness. Severe arteriosclerosis or other ischemic vascular diseases. Unbalanced cardiac insufficiency. Known or suspected deep vein thrombosis or thrombophlebitis. Gangrene. Dermatitis. Untreated or infected wounds. Severe inflammation of the skin. Recent skin grafts.
If you have NONE of the contraindications for use, AND have answered no to all the questions in the Screening Questionanaire, then please sign the following declaration.
I hereby affirm that I have answered the above questions truthfully to the best of my knowledge and have verified that I have none of the contraindications to using the Ballancer 404. If there is a change in my condition, I will immediately inform the operator of the Ballancer device. I hereby affirm that I am treated at my own risk.
Name: ______________________________________
Signature: ______________________________________
Date: ______________________________________
