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Intake Questionnaire
Date
First name
Last name
DOB
Phone
Age
Email
Street Address
Street Address Line 2
City
Postal / Zip code
Region/State/Province
Country
Reason for visit
Emergency Contact
Allergies (Medications, foods, etc.):
Current Medications: (Please include OTC & supplements)
Please briefly describe why you are seeking IV infusion or injection therapy? (For example: Are you looking to improve your energy, skin/hair/nail quality, recovery times, immune system, or hydration status? Are you seeking treatment for a hangover or looking to feeland look better)?
Please check any conditions that apply to you:
CARDIOVASCULAR AND RESPIRATORY
High Blood Pressure
Heart Murmur
Valve Disorder
Abnormal Rhythm
Chest Pain
Heart Attack
Cardiac Surgery or Stents
Congestive Heart Failure
Peripheral Artery Disease
Thrombosis or DVT
Aneurysm
Asthma
COPD
Sleep Apnea
Shortness of Breath
Pulmonary Hypertension
Lung Cancer
Other Lung Disorder
Other Cardiac Disorder
Other Lung Disorder
GASTROINTESTINAL AND URINARY
Acid Reflux
Bladder Disease
Kidney Disease
Liver Disease
Hepatitis A
Other
Other
NEUROLOGIC
Stroke/TIA
Multiple Sclerosis
Parkinson's
Alzheimer's
Seizures
Seizures? - date of last seizure
METABOLIC/ENDOCRINE AUTOIMMUNE
Hyper/Hypo Thyroid
Diabetes Type I Type II
Lupus
Rheumatoid Arthritis
Hx of DKA
Other
Other
HEMATOLOGY
Anemia
MTHER
G6PD Deficiency
Other Cardiac Disorder
MUSCULOSKELETAL
Back Pain
Carpal Tunnel Syndrome
Fibromyalgia
Degenerative Joint Disease
Degenerative Disk Disease
Other
CANCER
Chemotherapy
Radiation
Location of cancer
Location of cancer
PSYCHOLOGICAL
Depression
Anxiety or Panic Attacks
Suicidal Ideations
Other
WOMEN (non-menopausal)
Any chance that you are pregnant?
PAIN
CRPS
Fibromyalgia
Are you currently breastfeeding?
Do you drink alcohol or abuse any types of drugs? If so, please explain
Would you like to tell us anything else that you feel is important?
Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.?
I attest that the information I have provided is true and accurate to the best of my knowledge:
Your Signature
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