IV Therapy Intake Form

Intravenous (IV) Infusion Therapy Intake Form
Full Name*

First NameLast Name
Phone Number

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
In case of emergency, please contact:*

First NameLast Name
Phone Number*

Area CodePhone Number
What are your main complaints? (Please check all that apply)*

Recent surgical procedureRecent illnessCold or flu symptomsFacial wrinkles or fine linesDull or dry skinFatigue or low energyStressPoor diet due to busy lifestyleBrain fog or trouble concentratingLow mood or depressionHeadaches or migrainesWeight gain or difficulty losing weightSlow metabolismOther
Which statement(s) best describe why you are considering IV therapy? (Please check all that apply)*

I want to have more energy and feel better overallI want to do everything I can to nourish my bodyI want to do everything I can to enhance my weight loss effortsI want to prevent getting sickI want to recover quickly from surgery or illnessI want to feel and look youngerI want to have smoother, brighter and more vibrant skinI want to cleanse my body of toxinsI want to recover quickly from a hangoverOther
Medical History
Are you pregnant or breastfeeding?*

YesNo
Are you diabetic?*

YesNo
Are you a smoker?*

YesNo
If yes, how much do you smoke?
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
Do you use recreational drugs?

YesNo
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?

YesNo
Do you take any diuretics or water pills? If yes, please list below.

YesNo
Please list diuretic or water pill usage, if any.
Do you take any steroids i.e. Prednisone? If yes, please list below

YesNo
Steroid usage, if any.
Do you have any medication or food allergies? If yes, please list below.

YesNo
Do you have any of the following conditions? (Please check all that apply)

Blood pressure problems (High or Low)Heart ProblemsStroke or "Mini Stroke"Kidney ProblemsAsthmaOptic Nerve Atrophy or Leber's DiseaseSickle Cell AnemiaG6PD DeficiencySarcoidosisParathyroid 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?
Should be Empty:

Intravenous (IV) Infusion Therapy Intake Form