themontanaclinic.com - IV Therapy Form

IV Therapy Intake Form
1. Name:

First NameLast Name
DOB:

MonthDayYear
Date
2. MRN #:
PATIENT INTAKE FORM

Welcome to our online intake form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs.
ABOUT YOU
3. Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
4. Contact Information
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email Address
example@example.com
5. Demographic Information
Sex at birth:

MaleFemale
Marital Status:

SingleMarriedDivorcedWidowedOther
6. Spouse's Name
7. Number of Children
8. Personal Information
Height-Feet:
Height-Inches:
Weight (in pounds):
9. Emergency Contact Information
Emergency Contact Name:
Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient:
10. Employer Information
Employment Status:

EmployedStudentNot EmployedRetiredUnknown
Employer Name:
Occupation:
Physical Work Duties:
11. Physical Information
Referring Physician:
Referring Patient:
How did you hear about us?

Word of mouthAdvertisementSocial mediaDirect mail or email campaignEventInternetOther
12. Who is your Primary Care Physician (PCP)? Specialist? What are their phone numbers?
13. Do you have any allergies?
14. Do you have any allergies or sensitivity to blood thinners? (During the UBI/OZONE therapy, we use a small dose of heparin to keep the blood from clotting.)
15. Are you currently taking any of the following medications daily? or Any Nsaids or Blood Thinner medications not listed?

Eliquis/ApixabanIbuprofen/Motrin/AdvilDiclofenac/VoltarenXerelto/RivaroxabanNaproxen/AleveMeloxicam/AnjesoIndomethacin/ Indocin Aspirin/BabyAspirinCoumadin/WarfarinAspercreme/SalonpasCelebrex/CelecoxibNoneOther
16. Do you take medication for Atrial Fibrillation (A-Fib)?

YESNO
17. Have you been diagnosed Kidney Disease?

YESNO
18. Do you have any Blood Disorders? Thrombocytopenia? G6PD? Acute hemolytic anemia? Bleeding Organs? Recent Myocardial infarction less than 6 months ago? Hemorrhagic or Apoplectic Stroke?

YESNO
19. Do you have uncontrolled Hyperthyroidism?

YESNO
20. Are you currently being treated for any types of cancer? Leukemia?

YESNO
21. Are you Pregnant?

YESNO
22. Are you currently taking any Sulfa medications?

YESNO
23. What is you Past Medical History? (What have you been diagnosed by any medical professional)

HypertensionHigh CholesterolDiabetesStrokeHeart AttackCancerFibromyalgiaAbdominal DisordersHormone ImbalancesCongestive Heart FailureAsthma/AllergiesCOPDSkin conditionsGERD/refluxLong CovidRheumatoid ArthritisSeizures/EpilepsyOther
24. Please list all surgeries/procedures.
25. What is your Family Medical History? (Any physical or mental health conditions) Please list who and what conditions they have/had.

CancerDiabetesHeart AttackStrokeAuto Immune DisordersHypertensionMental Health DisordersSeizures/EpilepsyUnknown
26. Please list all medications and supplements. Please include dose and how many times a day you take each.
27. What are your main complaints? (Select all that apply)

Fatigue or low energyBrain fog or trouble concentratingWeight gain or difficulty loosing weightRecent surgical procedureFacial wrinkles or fine linesChronic Joint painStressLow mood or depressionSlow metabolismRecent illnessDull or dry skinPoor diet due to busy lifestyleHeadaches or migrainesAsthma and/or allergiesCold or Flu symptomsMalabsorption issues
28. Do you smoke?

YESNO
If yes, how much do you smoke and how long have you smoked?
29. How many alcoholic drinks do you consume in a week?

YESNO
30. Do you use recreational drugs?

YESNO
If yes, which ones and how often?
31. How much water do you drink daily? (Hydration is the key to the UBI/OZONE Therapy.)
32. When is the last time you had blood work? Were there any abnormalities/concerns?
33. Please upload all medical records, lab results and diagnostic testing to help us provide you with the best care possible.

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34. What are your goals to this treatment program?
35. Do you have any questions you would like to discuss with April Haugrose APRN before starting this treatment plan?

YESNO
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IV Therapy Intake Form

PATIENT INTAKE FORM

ABOUT YOU