Patient Medical History and Intake Form

Patient Medical History and Intake Form

Bottumzup Health and Wellness, LLC
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date Of birth*

MonthDayYear
Date
Age*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
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 RhythmChest PainHeart AttackCardiac Surgery or StentsCongestive Heart FailurePeripheral Artery DiseaseThrombosis or DVTAneurysmAsthmaCOPDSleep ApneaShortness of BreathPulmonary HypertensionLung Cancer
Other CARDIOVASCULAR AND RESPIRATORY
GASTROINTESTINAL AND URINARY

Acid RefluxLiver DiseaseBladder DiseaseHepatitis A, B, CKidney Disease
Other GASTROINTESTINAL AND URINARY
METABOLIC/ENDOCRINE/AUTOIMMUNE

Hyper/Hypo ThyroidRheumatoid ArthritisDiabetes Type I Type IIHx of DKALupusOther
Other METABOLIC/ENDOCRINE/AUTOIMMUNE
NEUROLOGIC

Stroke/TIASeizuresMultiple SclerosisAlzheimer’sParkinson’s
If you selected seizures, please list the date of the last seizure.
HEMATOLOGY

Anemia (Iron Deficiency, Pernicious, Aplastic,Hemolytic, Sickle Cell)MTHFRG6PD Deficiency
MUSCULOSKELETAL

Back PainDegenerative Joint DiseaseCarpal Tunnel SyndromeDegenerative Disk DiseaseFibromyalgia
Other MUSCULOSKELETAL
PSYCHOLOGICAL

DepressionSuicidal IdeationsAnxiety or Panic Attacks
CANCER

ChemotherapyChemotherapy
Location of cancer
WOMEN (non-menopausal)
Last Menstrual Period
Any chance that you are pregnant?

YesNo
Are you currently breastfeeding?

YesNo
PAIN

CRPSFibromyalgia
Do you drunk 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 like is important?
I attest that the information I have provided is true and accurate to the best of my knowledge:
Signature*

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Date*

MonthDayYear
Date
Full name*

First NameLast Name
Should be Empty: