Wellness Infusion Specialists Patient Medical History Form

General Patient Information
Patient Gender*
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Height (feet)*
Patient Height (inches)*
Patient Weight (pounds)*
Patient Telephone Number*
Please enter a valid phone number.
Patient E-Mail*
example@example.com
Reason for infusion :*
Patient Medical History
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackChest PainValve DiseaseHeart FailureAbnormal Heart RhythmBleeding DisorderRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaShortness of BreathUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseasePulmonary HypertensionEmphysemaDepressionAnxietyObsessive Compulsive DisorderMigrainesPost Traumatic Stress DisorderInsomniaSchizophreniaHallucinationsADD/ADHDSuicidalStrokeNeuromuscular DiseaseHistory of Psychiatric AdmissionAcute PainChronic PainFibromyalgiaHIVTuberculosisHepatitisSubstance AbuseRecreational Drug Use
Other Illnesses:
Please list any medication allergies:
Please list any Operations and Dates of Each
Please list your Current Medications
Personal Habits
Exercise

Never1-2 days3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Include other comments regarding your Medical History
Should be Empty:

General Patient Information

Patient Medical History

Personal Habits