Patient Medical History Form

Medical History Form
Patient Name*

First NameLast Name
Patient Gender*
Patient Birth Date*

MonthDayYear
Patient Height*
Patient Weight*
Patient E-Mail*
example@example.com
Patient Phone Number:*
Please enter a valid phone number.
Reason for seeking IV Infusion Therapy:*
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications, dosage , frequency, method of administration, indication and common side effects
Healthy & Unhealthy 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
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Desired appointment date and time
Please take a photo your ID*
Or upload a photo of your ID

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Signature*

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Medical History Form