Medical History Form
Full Name
First Name
Last Name
DOB:
xx-xx-xxxx
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal Goals:
Check any that you are concerned or interested in:
*
Fatigue
Headache
Post ETOH Ingestion
Nausea and or Vomiting
Vitamin Deficiency/MNT Test
Post Athletic Recovery
Anxiousness
Sleep Disturbance
Athletic Performance
Chronic Illness
Malaise
Skin Health
Acute Pain
Acute on Chronic Pain
Immune Support
I am interested in:
*
NAD+ Infusions
IV Therapy
IM Injections
Micronutrient Deficiency Testing
Other
Are You Pregnant: If YES, what Trimester are you in?
*
Yes
No
1st Trimester
2nd Trimester
3rd Trimester
Are You Breastfeeding? If YES, how old is your child?
*
Yes
No
0-6 Months Old
7-11 Months Old
1 year old
2 year old
Medications: (Please List All Supplements & Medications if none place put N/A)
*
Allergies: If No Allergies put N/A
*
Do You Care an Epi-Pen
Yes
No
List of Allergies/Reaction
*
Hay fever (itching of nose, stuffy nose, running nose
Asthma
Hives or Swelling
Eczema of other rashes (Poison Oak, etc)
Food Allergies
Immune Defect (frequent/recurrent infections)
Other: Please List
NKDA (No Known Drug Allergies)
NO ALLERGIES
Personal CARDIAC Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO CARDIAC HISTORY
Prolonged QT Syndrome
Heart Disease/Coronary Artery Disease or Vascular Heart Conditions Heart Attack? If Yes, within the last 6 months?
Do you have a Pacemaker or Defibrillator
Peripheral Arterial Disease
Arrhythmia (Abnormal heart beat)
High or Low Blood Pressure
Experience chest pain
Congestive Heart Failure
Heart Surgeries? If Yes, describe and Date of Surgery
Further Explanation:
Personal PULMONARY Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO PULMONARY HISTORY
Untreated Pneumothorax or current chest tube?
Asthma
COPD
Other Respiratory Problems If Yes please list:
Other
Further Explanation:
Personal ENDOCRINE Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO ENDOCRINE HISTORY
Diabetes Type 1
Diabetes Type 2
I take Anti-diabetic agents
Hypothyroidism
Hyperthyroidism
Further Explanation:
Personal BLOOD CIRCULATION & SKIN Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO BLOOD CIRCULATION OR SKIN HISTORY
Diagnosed with a blood disorder
Raynaud’s Phenomenon
Currently taking Sulfamylon
Bacterial or viral skin infections
Low platelet count
Open Wounds or Sores, If Yes, Please Specify Location & Treatment:
Diagnosed with anemia or abnormal bleeding
I have a blood clotting disorder
Deep Vein Thrombosis
I take blood thinners or Aspirin: If Yes, Please Specify What Medications:
Vasculitis
Hyperhydrosis (Severe Sweating)
G6PD Hereditary Deficiency
Further Explanation:
Have You Ever Been Diagnosed With An Auto-Immune Disorder? If Yes, Please Explain:
Personal KIDNEY/LIVER Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO KIDNEY OR LIVER HISTORY
Kidney Disease, If Yes, Please Explain:
Liver Disease, If Yes, Please Explain:
I’ve had a Transplant? If Yes, Please Explain:
Urinary Tract Disorder
Gallbladder Removed, If Yes, When Was Your Surgery:
Kidney Failure
Liver Failure
Polycystic Kidney's
Cirrhosis
Fatty Liver
Pancreatitis
Surgery on Kidney's or Liver, If Yes, Please Explain:
Further Explanation:
Personal NEUROLOGICAL Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO KIDNEY OR LIVER HISTORY
Chronic Pain, If Yes, Where is Your Pain Location:
I have a Pain Pump, If Yes, Please Specify:
Anxiety, If Yes How Are You Currently Managing Your Symptoms:
Depression, If Yes How Are You Currently Managing Your Symptoms:
Mental Health Disorder, If Yes, Please Specify Diagnosis:
Herniated Discs, If Yes, Did you or Are You Having Surgery? What Treatments Have You Tried:
History of Head Trauma, If Yes, When Was Your Accident and what Mechanism:
Migraines, If Yes, Frequency:
Neuropathy
Implanted Metal Devices in brain or spine, If Yes, Where:
History of Seizures, If Yes, When Was Your Last Event:
History of Stroke OR TIA, If Yes, When:
History of NECK AND OR BACK PAIN
Further Explanation:
Personal EYE/EAR/NOSE/MOUTH Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO EAR EYES NOSE OR THROAT HISTORY
Current Sinus or Ear Infection
Congestion or Ear/Nose/Head Pain
Eustachian Tube Dysfunction or difficulty “popping” ears
Recent dental procedures (1-2 weeks)
Chronic Sinusitis
Ear Surgery, If Yes, When:
Seasonal Allergies
Optic Neuritis
Central Retinal Artery Occlusion (CRAO)
Further Explanation:
Personal CANCER Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO CANCER HISTORY
HISTORY OF CANCER, If Yes, When were you diagnosed, What Type of Cancer & What type of Treatment:
IMMEDIATE FAMILY HX OF CANCER, If Yes, Please Specify Who and What Type:
I’ve had an abnormal PAP
Taking the following medications:
Bleomycin
Cisplatin
Doxorubicin
Further Explanation:
Personal GASTROINTESTINAL Medical History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO GASTROINTESTINAL HISTORY
Change in appetite
If Yes, When Did This Start?:
Weight Loss, If Yes, Please Specify:
Weight Gain, If Yes, Please Specify:
Trouble Swallowing, If Yes, Do You Have A Restricted Diet?
Intolerance of Food, If Yes, Please Specify Diagnosis or Type of Food Intolerance:
Nausea, If Yes, Have You Taken Any Anti-Nausea-Medications:
Vomiting, If Yes, When Was Your Last Emesis:
Diarrhea, If Yes, When Was The Last Episode:
Constipation
Abdominal Pain
Anorexia (Starvation), If Yes, Please Specify & When Was Your Last Event:
Bulimia (Purging), If Yes, Please Specify & When Was Your Last Event:
Abdominal Surgery, If Yes, When & What Type of Surgery:
Further Explanation:
Personal MUSCULOSKELETAL History: Have you ever been treated or are currently being treated for any of the following conditions?
*
NO MUSCLOSKELETAL HISTORY
Chronic Pain, If Yes, Where is Your Pain Location:
HX of Multiple Sclerosis, If Yes How Are You Currently Managing Your Symptoms & When Were You Diagnosed:
HX of Rhabdomyolysis, If Yes, When Was The Last Event?
Brody's Disease
Arthritis, If Yes, Please Specify Location:
Gout, If Yes, When Was Your Last Flare-Up:
Fibromyalgia, If Yes How Are You Currently Managing Your Symptoms:
Myasthenia gravis, If Yes, Please Specify Current Symptoms
Lou Gehrig's disease, If Yes, When Were Your Diagnosed:
Muscular Dystrophy, If Yes, When Were Your Diagnosed:
Muscle Spasms or Cramping, If Yes, Location & Frequency:
Tendonitis
Carpal-Tunnel Syndrome
Bone Fracture, If Yes, When & Location on Body:
Sprain or Strain, If Yes, When & Location on Body:
Stiff joints, If Yes, Where?
Further Explanation:
Personal GENERAL/SOCIAL History: Have you ever been treated or are currently being treated for any of the following conditions?
*
Alcohol Use? If Yes, Frequency & Drink Of Choice:
Do you take Disulfiram
If Yes How Long Have You Been Taking It:
Currently experiencing a fever, cold or flu-like symptoms, If Yes, What Symptoms How Long Have You Had Symptoms:
Claustrophobic
Known cold-contact allergy, If Yes, What Are Your Triggers:
Recently been diagnosed with a contagious illness, If Yes, Please Specify:
Recently been diagnosed with a contagious illness, If Yes, When Were Your Diagnosed & With What:
Are you currently diagnosed with HIV, TB, Hepatitis or any other infectious viral disease?, If Yes, Please Specify Which & When Were Your Diagnosed:
Hospitalizations / Operations, If Yes, When & What Operation:
Body dysmorphic disorder
Tobacco Use, If Yes, Frequency:
CBD Use, If Yes, Please Specify Dosage:
Marijuana Use, If Yes, How Frequently?:
Recreational Drug Use, If Yes, What Are Your Currently Using and How?
NONE OF THESE APPLY TO ME
Further Explanation:
Medical Care or Seeing A Specialist
*
I AM NOT CURRENTLY SEEING A SPECIALIST
Currently under a physician's care for any diagnosis not listed above? If Yes, Please Specify:
I am currently being seen by a specialist for my health?
Is there anything additional we need to know in order to care for you today?, If Yes, Please Specify:
Further Explanation:
I am interested in receiving & understand that:
*
Services in-clinic: No Additional Charges
Services @ Home:Requires an additional $75 charge for up to 4 people
NAD Loading Dose ($200 Includes all 4 loading doses up to 4 people)
Concierge IV Service Package (6 Sessions for $400-$66/Session)
Concierge IV Service Package (12 Sessions for $600-$50/Session)
I will decide later which option I would like
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