Patient Intake Form
9th Cloud Wellness
Full Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
What is your gender?
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Occupation (for Discounts!)
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever been told you have an electrolyte imbalance or other abnormal labs?
*
Hypermagnesemia (High Magnesium Levels)
Hypercalcemia (High calcium Levels)
Hypokalemia (Low potassium Levels)
Hemochromatosis (High Iron Levels)
No, I have not
Other
Do you have or have you experienced any of the following conditions?
*
Blood Pressure Problems (High or Low)
Kidney Stones
Sickle Cell Anemia
Parathyroid Problems (High Levels)
Heart Problems
Asthma
G6PD Deficiency
Stroke or "mini-stroke)
Optic Nerve Atrophy or Leber's Disease
Sarcoidosis
Kidney Problems
Type 1 Diabetes
Type 2 Diabetes
No, I do/have not
Other
Are you currently taking any medication?
*
Yes
No
What medical conditions do you have?
Do you have any medication allergies?
*
Yes
No
Not Sure
Please list them.
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Have you taken any illicit drugs today?
*
Yes
No
For your safety, list drugs that might be in your system. Remember, we aren't the cops, brother.
Is there any else you think we should know?
*
Are interested in learning about Ketamine Infusion Therapy?
*
Please Select
Yes
No
Are interested in learning about Hormone Replacement Therapy?
*
Please Select
Yes
No
Are interested in learning about Peptide Therapy?
*
Please Select
Yes
No
Submit
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