IV Therapy Questionnaire

IV Nutrient Therapy

Please select your preferred IV Therapy*

Date of Birth

MonthDayYear

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

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Email

example@example.com

Patient Referral (Email)

1. Are you between the ages of 18 and 70?

YesNo

2. Do you have a history of Kidney dysfunction, liver disease, active skin disease, bleeding/clotting disorders, congestive heart failure, uncontrolled high blood pressure or heart arrhythmias?

YesNo

Note: 1

3. Do you have a current diagnosis of anemia due to blood loss?

YesNo

Note: 2

4. In the treatment area, do you have any inflammation, infections, wounds, other skin disorders or permanent implant on or in the areas of the body that will be treated?

YesNo

Note: 3

5. Are you pregnant?

YesNo

Note: 4

Questions: 1. Do you have or have a history of: Kidney dysfunction, liver disease, active skin disease, bleeding/clotting disorders, congestive heart failure, uncontrolled high blood pressure or heart arrhythmias?

Patients with impaired kidney or liver function may have difficulty metabolizing and excreting the substances delivered through IV therapy. This can lead to an increased risk of toxicity or adverse reactions. Similarly, patients with bleeding or clotting disorders may be at risk of complications during IV administration, such as hematoma formation or difficulties with clotting.

2. Do you have a current diagnosis of anemia due to blood loss?

Anemia can affect the body's ability to transport oxygen and nutrients effectively. IV Nutrient Therapy may need to be adjusted to address anemia

3. In the treatment area, do you have any inflammation, infections, wounds, other skin disorders or permanent implant on or in the areas of the body that will be treated?

Infections, wounds, or active skin diseases in the treatment area can increase the risk of introducing contaminants into the bloodstream during IV therapy. Additionally, permanent implants can pose challenges in accessing veins and may require alternative administration routes.

5. In the next 24 hours will you breastfeed if you are receiving Vitamin C, Zinc, MIC, Glutathione, Toradol, Zofran, Benadryl, Vitamin D and Promethazine?

6. In the next 24 hours will you breastfeed if you are receiving Vitamins C, Zinc, MIC, Glutathione, Toradol, Zofran, Benadryl, Vitamin D and Promethazine?

YesNo

Note: 5

7. In the past, have you ever had an adverse reaction to IV therapy?

YesNo

Note: 6

8. Are you currently experiencing an outbreak of any viruses (HSV I/HSV II)?

YesNo

Note: 7

9. Do you have any allergy to any of the following: Sulfur, Sulfites, Saline (sodium chloride), Vitamin C (ascorbic acid), B complex (include B1-B7 and B12), Glutathione, magnesium chloride, zinc sulfate, NAD+, MIC (methionine, inositol, choline), Pepcid (famotidine), Toradol (ketorolac), Zofran (ondansetron) or Benadryl?

YesNo

Note: 8

10. What allergies do you have? Write NA if no allergies.

Note: 9

11. Are you currently taking digoxin?

YesNo

Note: 10

12. Do you have B12 Folic Acid deficiency?

YesNo

Note: 11

13. Are you currently taking any anticoagulants? If yes, please indicate which medications.

YesNo

Note: 12

14. Do you have high or low blood pressure?

YesNo

Note: 13

15. Do you have hypercalcemia, sarcoidosis or hypophosphatemia?

YesNo

Note: 14

Digoxin is a medication used to treat heart conditions, and its interaction with some substances used in IV therapy may lead to adverse effects. It is essential to assess the patient's current medications to avoid any potential drug interactions.

10. Do you have B12 Folic Acid deficiency?

This question is not a contraindication. Instead, it helps identify patients with B12 Folic Acid deficiency, which can influence the choice and dosage of specific nutrients used in IV therapy to address the deficiency effectively. If yes: please indicate in answer, and upon submission approval, ask provider to

11. Are you currently taking any anticoagulants?

Patients on anticoagulant medications have an increased risk of bleeding. This question is crucial as it guides the healthcare provider to take specific precautions, such as using the smallest gauge needle and catheter, and closely monitoring the patient during the IV therapy to prevent hematoma formation. Yes is not a contraindication. Please indicate which medications in answer, and copy/paste "Patient has increased risk of hematoma formation, use smallest gauge needle, catheter and monitor patient." When submitting for approval, please indicate in notes to, "Review Answers."

12. Do you have high or low blood pressure?

High or low blood pressure levels can impact how the body responds to IV therapy. Monitoring the patient's blood pressure before and after treatment is essential to ensure the therapy's safety and effectiveness. (Yes is not a contraindication, in notes write, "Patient has blood pressure concerns, administering provider should take vitals. If above 150/90 or below 90/50, patient should not be cleared for IV Nutrient Therapy.") In submission notes write, "Please take patient vitals (Blood Pressure, Heart Rate, Temperature and Oxygen Saturation) before and after treatment."

13. Do you have hypercalcemia, sarcoidosis or hypophosphatemia?

These medical conditions may interact with specific substances used in IV nutrient therapy, and caution is needed to prevent complications. Yes is not a contraindication, in Notes please write,

"Patient cannot receive Calcium Gluconate in IV."

16. Are you diabetic? Diabetic patients have specific restrictions on certain substances used in IV therapy.

YesNo

Note: 15

17. Are you currently taking any antidepressants?

YesNo

Note: 16

18. Do you have hypothyroidism?

YesNo

Note: 17

19. Do you have an allergy to Shellfish, Cobalt or Acetylcysteine?

YesNo

Note: 18

20. What medications are you currently taking? Write NA if no medications.

21. Are you feeling dehydrated due to sweating or lack of fluid intake?

YesNo

22. Patient notice and consent. This treatment has Black Box warning. Very rare but potential risk for medullary cancer. Seen in rodent studies, never seen in human trials. In addition to common potential side effects: Nausea, decrease in appetite, stomach pains and discomfort, headache, tiredness, constipation and elevated heart rate. Do you consent to be treated with GLP-1 agonists?

YesNo

This question is a contraindication because some of the substances listed in IV Nutrient Therapy + (such as medications and high-dose nutrients) can pass into breast milk and be ingested by the nursing baby. Depending on the substance and its dosage, this can potentially have adverse effects on the infant's health, development, or overall well-being. Vitamin C: In moderate to high doses, vitamin C can increase the acidity of breast milk, potentially causing digestive discomfort in the nursing infant. Zinc: High doses of zinc in breast milk may lead to gastrointestinal disturbances in the baby. MIC (Methionine, Inositol, Choline): The effects of MIC on breastfeeding infants are not well- studied, and it is generally recommended to avoid during breastfeeding unless otherwise indicated by a healthcare provider. Glutathione: Glutathione is present naturally in breast milk, but the effects of supplemental glutathione on nursing infants are not well-established. Toradol (Ketorolac): Toradol is a nonsteroidal anti-inflammatory drug (NSAID) and is generally not recommended during breastfeeding due to potential adverse effects on the baby's developing kidneys. Benadryl (Diphenhydramine): Benadryl is an antihistamine that can cause drowsiness in both the mother and the baby if transferred through breast milk. Promethazine: Promethazine is an antihistamine with sedative properties, and it may cause drowsiness in breastfeeding

6. In the past, have you ever had an adverse reaction to IV therapy?

A history of adverse reactions may indicate sensitivity to certain substances or indicate an increased risk of similar reactions during future IV treatments.

7. Are you currently experiencing an outbreak of any viruses (HSV I/HSV II)?

Active viral infections can interact with IV therapy and may necessitate postponing treatment to avoid exacerbating the infection or transmitting the virus.

8. Do you have any allergy to any of the following: Sulfur, Sulfites, Saline (sodium chloride), Vitamin C (ascorbic acid), B complex (include B1-B7 and B12), Glutathione, magnesium chloride, zinc sulfate, NAD+, MIC (methionine, inositol, choline), Pepcid (famotidine), Toradol (ketorolac), Zofran (ondansetron) or Benadryl?

If yes to a specific ingredient like Vitamin C, B complex (include B1-B7 and B12), Glutathione, magnesium chloride, zinc sulfate, NAD+, MIC, Pepcid, Toradol, Zofran or Benadryl. Do not defer entire exam. Rather Chart: "Patient has allergy to *list ingredients/medications* and cannot receive it in the IV."

9. Are you currently taking digoxin?

Diabetic patients have specific restrictions on certain substances used in IV therapy. This question helps identify patients who cannot receive Alpha Lipoic Acid or Glucosamine Sulfate in IV due to their diabetic condition. Yes is not a contraindication. In Notes, please write "Patient is diabetic, cannot receive Alpha Lipoic Acid or Glucosamine Sulfate in IV."

15. Are you currently taking any antidepressants?

Selective Serotonin Reuptake Inhibitors (SSRIs), MAO inhibitors, tricyclic antidepressants and atypical antidepressants) Reason: Some antidepressant medications may interact with substances used in IV therapy. Tryptophan and Benadryl, for example, should not be administered to patients on SSRIs.Yes, is not a contraindication, in Notes please write, "Patient is on SSRIs, cannot receive Tryptophan

16. Do you have hypothyroidism?

Patients with hypothyroidism should not receive Selenium in IV, as it may interfere with their condition. Yes is not a contraindication, in Notes please write, "Patient has hypothyroidism and cannot receive Selenium

17. Do you have an allergy to Shellfish, Cobalt or Acetylcysteine?

Patients with allergies to these substances should not receive them in IV to prevent allergic reactions. Yes is not a contraindication. In notes, please write "patient has a (insert here) allergy, and cannot receive it in the