Intake Questionnaire
Date:
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Month
-
Day
Year
Date
Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Age:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Reason for visit:
Emergency Contact:
Allergies (Medications, foods, etc.):
Current Medications: (Please include OTC & supplements)
Please check any conditions that apply to you:
CARDIOVASCULAR AND RESPIRATORY
CARDIOVASCULAR AND RESPIRATORY conditions
High Blood Pressure
Heart Murmur
Valve Disorder
Abnormal Rhythm
Chest Pain
Heart Attack
Cardiac Surgery or Stents
Congestive Heart Failure
Peripheral Artery Disease
Thrombosis or DVT
Aneurysm
Asthma
COPD
Sleep Apnea
Shortness of Breath
Pulmonary Hypertension
Lung Cancer
Other Lung Disorder
Other Cardiac Disorder
GASTROINTESTINAL AND URINARY
GASTROINTESTINAL AND URINARY conditions
Acid Reflux
Bladder Disease
Kidney Disease
Liver Disease
Hepatitis A, B, C
Other
METABOLIC/ENDOCRINE/AUTOIMMUNE
METABOLIC/ENDOCRINE/AUTOIMMUNE conditions
Hyper/Hypo Thyroid
Diabetes Type I Type II
Lupus
Rheumatoid Arthritis
Hx of DKA
Other
NEUROLOGIC
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Intake Questionnaire
Stroke/TIA
Multiple Sclerosis
Parkinson's
Seizures - date of last seizure
-
Month
-
Day
Year
Date
Alzheimer's
HEMATOLOGY
Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell)
MTHFR
G6PD Deficiency
MUSCULOSKELETAL
Back Pain Degenerative Joint Disease
Carpal Tunnel Syndrome
Degenerative Disk Disease
Fibromyalgia
Other
PSYCHOLOGICAL
Depression
Anxiety or Panic Attacks
Suicidal Ideations
CANCER
Location of cancer
Chemotherapy
Radiation
WOMEN (non-menopausal)
Last Menstrual Period
-
Month
-
Day
Year
Date
Any chance that you are pregnant?
Are you currently breastfeeding?
PAIN
CRPS
Fibromyalgia
Please briefly describe why you are seeking IV infusion or injection therapy?
Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.?
Signature
Date
-
Month
-
Day
Year
Date
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