Do they understand how to use it? *

• Plug it in, turn it on, press the button. • Touch the black side of the applicator.

Yes

Do they know when to use it? *

• Twice a day, 8-12 hours apart. • Back-to-back is not likely to be as beneficial as 8-12 hours apart

Yes

Did you help them schedule treatments into their day? *

• While you’re eating breakfast and with the evening news. • In bed before you get up and before you fall asleep.

Yes

Did you help them set up a treatment station? *

• Where to sit and leave the device for easy access every day/night. • How to position the applicator(s) for the best energy coverage. • How to use pillows, tape or bandages to hold the applicators in place.

Yes

Do they understand how the technology works? *

• Replexa+ is shortwave diathermy, electromagnetic energy. • Indicated to relieve pain, increase blood flow and stimulate cellular activity.

Yes

Do they know what to expect to feel during treatment? *

• Most patients don’t feel anything • Some patients say they feel a warming sensation, hum or slight tingle

Yes

Do they know what to when to expect to feel improvement? *

• A noticeable change is likely to happen in the first 30 days. • The better they are at getting their treatments in, the faster the results. • Patients typically have the device for 90+ days.

Yes

Do they know whom to call if they have any questions or issues with the device? *

• ProMedTek toll-free number on the Instruction Manual and device. • 866-388-2410

Yes

Date *

MM

DD

YYYY

Inservice By *

First Name

Last Name

Patient Name *

First Name

Last Name

Text Friendly *

Yes

No

Best Time *

Hour

Minute

Second

AM PM

Alternative Phone Number *

(###)

###

####

Location *

Choose one or more

Foot

Back

Arm

Ankle

Spine

Hand

Knee

Shoulder

Upper

Heel

Neck

Lower

Leg

Head

Right

Hip

Elbow

Left

Current Restrictions

Walking

Standing

Sitting

Sleeping

Lifting

Bending

Overall

Mobility

Goals

Choose one or more

Improve Mobility

Resume Activities

Reduce Pain/Swelling

Improve Sleep