• Returning IV Patient | Pre-Infusion Update

    Complete before each return infusion. Tell us about changes since your last visit and any symptoms today. Prior treatment does not guarantee that another infusion is appropriate. Your clinician must review this form and decide whether to proceed; this is not treatment consent or clearance. Do not stop prescribed medicines unless your prescriber instructs you. This form is not monitored continuously. For chest pain, severe trouble breathing, stroke symptoms, fainting with ongoing symptoms or a severe allergic reaction, call 911; do not wait for a reply.

  • Return IV Visit

  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Screening date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Appointment date
  • Format: (000) 000-0000.
  • Have you completed the full New IV Patient health screening?*
  • Screening note

  • Last infusion

  • Did you have any symptoms or reaction during or after your last infusion?*
  • Did you need urgent care or emergency treatment after your last infusion?*

  • Current symptoms

  • Do you currently have chest pain, severe trouble breathing, new weakness or confusion, or tongue or throat swelling?*
  • Do you currently have a fever, an acute illness, or are you being treated for an infection?*
  • Do you currently have new swelling, shortness of breath, very little urine, or trouble keeping fluids down?*
  • Do you have any rash, wound, infection, or persistent pain at a possible IV site?*
  • Emergency symptoms: if you have chest pain, severe trouble breathing, stroke symptoms, fainting with ongoing symptoms, or a severe allergic reaction, call 911 and do not wait for a reply.

  • Changes since last infusion

  • List any changes since your last infusion. If yes/unsure, provide details for each item.
  • Any new diagnosis, ER visit, hospitalization, surgery, or instruction from a clinician to avoid an infusion?*
  • Any change in heart condition, blood pressure, or fluid restriction?*
  • Any change in kidney function, dialysis, or kidney stones?*
  • Any change in liver disease or liver tests?*
  • Any change in electrolytes?*
  • Any newly identified G6PD deficiency, anemia, iron overload, or bleeding problem?*
  • Any change in diabetes or glucose control?*
  • Any change in cancer treatment, immune suppression, or seizure disorder?*
  • Any new allergies or reactions?*
  • Any prescription, over-the-counter medicines, vitamins, herbs, or supplements started, stopped, or changed in dose?*

  • Every-visit check

  • Pregnancy status*
  • Breastfeeding status*
  • Substance use in the past 24 hours*
  • Eaten in the past 2–3 hours*
  • Had fluids in the past 2–3 hours*
  • Arm restriction or new IV access issue*

  • Cannabinoid discussion

  • Today’s discussion includes PICO IV, Core-A, CBD, or another cannabinoid product?*
  • This section gathers safety information only; it does not establish product availability, approval, or suitability.
  • Have you had any new reactions to a cannabinoid product?
  • Are you experiencing any of the following concerns: excessive sedation, liver concerns, drug testing concerns, or other related issues?
  • If you feel impaired today, is safe transportation available?

  • Final

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: