Nurse Consultation Intake Form
There is a $25 nonrefundable fee for this service that goes towards your session. This is not a GFE.
Patient Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Do you have any medical compaints or concerns?
Lifestyle/ Health Conditions/ Medical Concerns: (check all that apply)
Fatigue
Low Depressed Mood
Anemia
Weight Issues
Irritability/Moodiness
Trying to get Pregnant/Fertility Prep
Stress
PMS
Allergies
Sleep Disorders
Asthma
IBS/Inflammatory Bowels
Low Immunity
Digestive Issues
Numbness/Tingling of the body
Migraines
Muscle Spasms
Aging
Aching Joints
Sexual Dysfunction
Ankle Swelling
Asthma
Anxiety
Edema
Sudden Weight Loss
Covid Vaccine?
Last Menstrual Cycle
History of Blood Clots
Blood Thinners
Drink Alcohol
Smoke
Pregnant
Keto Diet
Skin Issues
Medical History: (past or current)
HIV/ AIDS
Skin Disease (Eczema or psoriasis)
Cancer
Lipid Disorders (high cholesterol)
Parkinsons
Autoimmune Issues
High/ Low Blood Pressure
Arrythmia
Congestive Heart Failure
Angina
Erectile Dysfunction
MI/ Heart Attack
Diabetes
Bleeding Disorder
Kidney Disease
Asthma
G6PD Deficiency
Anemia
Gout or Arthritis
Heart Disease
Kidney Disease
Stroke
Covid Vaccine?
Last Menstrual Cycle
History of Blood Clots
Liver Disease (i.e., Cirrhosis, hepatitis)
Lyme Disease
Abnormal EKG
Thyroid Disorder
Have you received EBOO Therapy before?
Yes
No
Do you have an Ozone Allergy?
Yes
No
Do you currently have cancer? If so, what stage and time of diagnosis:
Are you currently on Chemotherapy? (helps increase the efficacy of chemotherapy treatment)
Yes
No
Has anyone ever had an issue with finding your vein? (only size 18 or 20 needles can be used)
Yes
No
Do you have Low Hemoglobin?
Yes
No
Have you had a recent Heart Attack? (must wait one month)
Yes
No
Do you have Thrombocytopenia?
Yes
No
Do you have G6PD insufficiency?
Yes
No
Do you have Severe hypertension?
Yes
No
Do you have a Thyroid disorder?
Yes
No
Did you take the Covid Vaccine?
Yes
No
If you took Covid Vaccine, when was the last time you were vaccinated?
Are you currently pregnant?
Yes
No
Are you currently on your menstral cycle?
Yes
No
Date of Last Menstrual Cycle:
Do you have a history or stroke?
Ischemic
Hemorrhagic
No history of stroke
Are you diabetic?
Type 1
Type 2
No history of diabetes
Please list current Medications including herbal supplements: (No vitamin C, wait 3 days after EBOO to resume)
Configurable list
*
Submit
Should be Empty: