Patient Medical History and Intake Form

Patient Medical History and Intake Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Height*
Weight*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Reason for visit*
Emergency Contact*
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 feel and look better?*
Allergies (Medications, foods, etc.)*
Current Medications: (Please include OTC & supplements)*
Please check any conditions that apply to you:
CARDIOVASCULAR AND RESPIRATORY

High Blood PressureHeart MurmurValve DisorderAbnormal Heart RhythmChest PainHeart AttackCardiac Surgery or StintsCongestive Heart FailurePeripheral Artery DiseaseThrombosis or DVTAneurysmAsthmaCOPDSleep ApneaShortness of breathPulmonary HypertensionLung CancerOther Lung Disorder
GASTROINTESTINAL AND URINARY

Acid ReflexBladder DiseaseKidney DiseaseLiver DiseaseHepatitis A, B, COther
METABOLIC/ENDOCRINE/AUTOIMMUNE

Hyper/Hypo ThyroidRheumatoid ArthritisDiabetes Type IHx of DKADiabetes Type IIOther
NEUROLOGIC

Stroke/TIAAlzheimer's diseaseMultiple SclerosisSeizuresParkinson's
Date of last seizure

MonthDayYear
MUSCULOSKELETAL

Back PainDegenerative Disk DiseaseCarpal TunnelFibromyalgiaOther
PSYCHOLOGICAL

DepressionSuicidal IdeationsAnxiety or Panic AttacksOther
PAIN

Complex Regional Pain SyndromeFibromyalgiaOther
CANCER
Location of cancer
Chemotherapy
Radiation
Immunotherapy
WOMEN (non-menopausal)
Last Menstrual Period
Any chance that you are pregnant?
Are you currently breastfeeding?
Do you drink alcohol or abuse any types of drugs? If so, please explain
Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.?
Would you like to tell us anything else that you feel is important?
I attest that the information I have provided is true and accurate to the best of my knowledge:
Today's Date*

MonthDayYear
Date
Signature*

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