Infusion Intake Form
Detailed Medical History | Current Symptoms Review
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Weight
Height
Gender
Please Select
Male
Female
Phone Number
Please enter a valid phone number.
Email
example@example.com
Drivers License #:
As a telemedicine provider company, your picture ID (driver's license, State ID, or passport) is a prerequisite for any of our services to verify your age and identity
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Which Treatment are you interested in?
*
Please Select
IV Infusion
TRT
Peptides
Have you ever had an infusion before?
Yes
No
Have you ever done Hormone replacement therapy before?
Yes
No
Have you got blood work done in the past 30 days?
Yes
No
General Health
Excellent
Good
Fair
Poor
Medical History - Identify any present and past health concerns. Choose NONE if applicable
Present
Past
Comments
Hypertension
Abnormal Heart Rhythms
Bleeding/Clotting Disorder
Sudden Weight Loss
Chest Pain
Chronic Heart Failure
CVA/Stroke/TIA or mini-stroke
Thyroid Problems
Kidney Disease
Depression
Anxiety/Panic Attacks
Asthma
Diabetes
Ankle Swelling
Generalized Edema
Pulmonary Edema
Are you pregnant?
Allergic Reactions
Seizures
Anemia
Head Injury
None
Details of any of the above or any other medical considerations, i.e.: Autoimmunity, chronic illnesses, mold toxicity, viral illness, parasites, bacteria/yeast infection, neurological conditions, alcoholism, cancer, frequent infections, arthritis, nutritional deficiencies, etc.
Describe any current symptoms and duration if not addressed above, i.e.: GI upset, skin problems, pain, inflammation, headaches, sleep problems, fatigue,
Treatments or therapies tried:
Have you had a COVID-19 vaccination and Booster? If yes, please indicate when you received your last dose. If you plan on getting the vaccine soon, please indicate your scheduled date as this is important when considering IV therapy. Also note if you have received a Booster and date.
Current Medications: (Include prescriptions, over-the-counter medicines, supplements/vitamins, etc. with dose/frequency)
*
Allergies to any medications or foods: (List medication or food and reaction)
*
Do you follow a special diet? if so, please describe.
Do you exercise? if so, what type of exercise?
How did you hear about us?
Signature
*
Date
*
-
Month
-
Day
Year
Date
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