Registration - Reset Chair

Reset Chair Registration

  • Personal Information
  • Health Problem
  • Your Lifestyle
  • General Health

Please fill out the details below.

First Name

Last Name

ID

Gender

Date of Birth

Occupation

Address (House No. & Street, Town/City, Province/State, Postal Code)

Phone Number

Email Address

How did you hear about the Reset Chair?

Health Problem

Which of the following health issues are you experiencing?

Please fill out the questions accordingly depending on the health problem you're experiencing.

Incontinence (Men or Women)

How many times do you get up to urinate at night?

Do you have a strong urge to urinate during the day and hardly have time to find a bathroom?

Do you think you have finished urinating but a little more comes out later and soils your clothes?

Do you suffer from urinary infections off and on?

Do you use pads, urinary collection bags or adult diapers?

Have you had any medical treatment for your condition?

Are you taking any medication for your condition?

Low Sexual Libido (Men or Women)

Since when have you noticed your libido has weakened?

Have you had any treatment for this condition?

Are you taking any medication for low libido?

Are you taking any herbal supplements for libido?

Enlarged Prostate - BPH (Men)

Since when have you noticed this problem?

Have you had any treatment for this condition?

Are you taking any medication for BPH?

Are you taking any natural supplements for BPH?

Erectile Dysfunction - ED (Men)

Since how long have you started having this problem?

Do you usually have an erection in the early morning?

Do you often lose your erection when you make love?

Are you taking any medicine for ED?

Are you taking any natural supplements for ED?

Have you had any treatments for this condition?

If yes, what treatments?

Please answer each question according to your lifestyle.

Do you go for 20 minutes or more walks daily?

Do you go to a gym 2 or 3 times weekly?

Do you have some kind of exercise program?

Do you suffer from insomnia?

Do you smoke?

How many glasses of alcohol do you drink daily?Weekly?

Do you drink mostly hard liquor or wine/beer?

Do you often suffer from constipation?

Are you mostly a Vegetarian?

What is your main source of protein?

Do you eat any of the following weekly? Red meat, Ham, Sausages Hamburger, Pork, Chicken, Sea food (shrimp, lobster, shellfish, clams)

Do you eat store bought pastries?

Do you eat commercial ice cream?

Do you eat deep fried foods?

Do you drink soft drinks?

Please answer each question according to your general health.

Please tell us about any relevant medical history

If you suffer pain, where is it located?

On a scale of 1 to 10, how bad is the pain (1 being mild, 10 being severe)

In the last 5 years, what was your biggest emotional shock?

What pharmaceutical medications are you currently taking?

What natural herbal supplements are you currently taking?

Your Declaration

By ticking this box, you agree to our Terms of Service and Privacy Policy regarding how we use your personal data.

Feel free to read our Terms of Service and Privacy Policy.

Our Success Stories

The RESET CHAIR® has been used in various clinics.  Here is a CHART where incontinence was mostly treated. It shows that those who did the amount of sessions recommended in most cases had 100% successful results.

This site is registered on wpml.org as a development site.