Intravenous (IV) Infusion Therapy Intake Form
Full Name
*
First Name
Last Name
Phone Number
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Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
In case of emergency, please contact:
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First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
What are your main complaints? (Please check all that apply)
*
Recent surgical procedure
Recent illness
Cold or flu symptoms
Facial wrinkles or fine lines
Dull or dry skin
Fatigue or low energy
Stress
Poor diet due to busy lifestyle
Brain fog or trouble concentrating
Low mood or depression
Headaches or migraines
Weight gain or difficulty losing weight
Slow metabolism
Other
Which statement(s) best describe why you are considering IV therapy? (Please check all that apply)
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I want to have more energy and feel better overall
I want to do everything I can to nourish my body
I want to do everything I can to enhance my weight loss efforts
I want to prevent getting sick
I want to recover quickly from surgery or illness
I want to feel and look younger
I want to have smoother, brighter and more vibrant skin
I want to cleanse my body of toxins
I want to recover quickly from a hangover
Other
Medical History
Are you pregnant or breastfeeding?
*
Yes
No
Are you diabetic?
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Yes
No
Are you a smoker?
*
Yes
No
If yes, how much do you smoke?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Do you use recreational drugs?
Yes
No
If yes, please which ones and how often?
Please list everything you are currently taking:
Prescription Medications - Strength - Frequency - Condition being treated
Over the Counter Medications - Strength - Frequency - Condition being treated
Vitamins and Other Supplements - Strength - Frequency - Condition being treated
Do you take Digoxin (Lanoxin) for a heart problem?
Yes
No
Do you take any diuretics or water pills? If yes, please list below.
Yes
No
Please list diuretic or water pill usage, if any.
Do you take any steroids i.e. Prednisone? If yes, please list below
Yes
No
Steroid usage, if any.
Do you have any medication or food allergies? If yes, please list below.
Yes
No
Do you have any of the following conditions? (Please check all that apply)
Blood pressure problems (High or Low)
Heart Problems
Stroke or "Mini Stroke"
Kidney Problems
Asthma
Optic Nerve Atrophy or Leber's Disease
Sickle Cell Anemia
G6PD Deficiency
Sarcoidosis
Parathyroid Problems (High Levels)
Other
List all surgical procedures with approximate dates, if any:
Is there anything else you would like the nurse or physician to be aware of?
Submit
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