New IV Patient | Pre-Infusion Health Screening
DRAFT FOR CLINIC REVIEW. Do not enter real patient information until the clinic enables this form. Your answers help your clinician review whether the proposed IV treatment is appropriate. This questionnaire is not treatment consent, a diagnosis, or approval to receive an infusion. Treatment requires a separate clinical evaluation, order, and consent. Do not stop prescribed medicines unless your prescriber instructs you. This form is not monitored continuously. For chest pain, severe breathing difficulty, stroke symptoms, fainting with ongoing symptoms, or a severe allergic reaction, call 911; do not wait for a form response.
About you
Full legal name
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First Name
Middle Name
Last Name
Date of birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Screening date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Height (with units)
Weight (with units)
Emergency contact name
*
First Name
Middle Name
Last Name
Emergency contact relationship
*
Emergency contact phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Which infusion or add-on are you discussing with your clinician?
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Primary care clinician
Symptoms today
Currently experiencing chest pain, severe trouble breathing, new one-sided weakness, confusion, or swelling of the tongue/throat?
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No
Yes
Unsure
Currently have fever, an active infection, or feel acutely unwell?
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No
Yes
Unsure
Have persistent vomiting or diarrhea, very little urine, or difficulty keeping fluids down?
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No
Yes
Unsure
Have a skin infection, rash, wound, or redness near either arm or hand where an IV might be placed?
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No
Yes
Unsure
If you answered Yes or Unsure to any item above, briefly explain the symptom(s) and when they started. Enter None if all No.
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Heart and fluid balance
Have you ever been diagnosed with heart failure or another heart condition?
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No
Yes
Unsure
If Yes or Unsure, explain any heart or fluid concerns (condition, dates, treatment, and current status). Enter None if none.
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Do you have uncontrolled high blood pressure?
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No
Yes
Unsure
Have you had low blood pressure or unexplained fainting?
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No
Yes
Unsure
Do you have fluid retention, swelling, or a prior episode of fluid overload?
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No
Yes
Unsure
Have you ever had a blood clot, deep vein thrombosis (DVT), or pulmonary embolism?
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No
Yes
Unsure
Have you been prescribed a fluid restriction or sodium restriction?
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No
Yes
Unsure
Kidney/liver
Do you have chronic kidney disease or kidney failure?
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No
Yes
Unsure
Are you currently on dialysis?
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No
Yes
Unsure
Have you had kidney stones or oxalate kidney disease?
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No
Yes
Unsure
Follow prescribed fluid restrictions. We will recheck on arrival; do not drink excess fluids to satisfy this question.
Do you have liver disease, hepatitis, cirrhosis, or abnormal liver blood tests?
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No
Yes
Unsure
Have you had abnormal sodium, potassium, calcium, magnesium, or other electrolyte levels?
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No
Yes
Unsure
Blood, metabolic, and immune history
Diagnosed G6PD deficiency?
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Yes
No
Unsure
If Yes or Unsure, explain G6PD deficiency status. No known G6PD deficiency does not establish a normal test.
Ever tested for G6PD?
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Yes
No
Unsure
If Yes or Unsure, describe G6PD test result and date (if known).
Have you ever been told you have anemia or another blood disorder?
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Yes
No
Unsure
Have you ever had hemochromatosis or iron overload?
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Yes
No
Unsure
Do you have a bleeding disorder or take blood-thinning medicine?
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Yes
No
Unsure
If Yes or Unsure, explain any kidney or liver concerns (condition, dates, treatment, and current status). Enter None if none.
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Do you have diabetes?
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Yes
No
Unsure
Do you use insulin or other glucose-lowering medicine?
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Yes
No
Unsure
Do you have an active or chronic infection?
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Yes
No
Unsure
Do you have a weakened immune system, transplant history, cancer treatment, or immunosuppressant therapy?
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Yes
No
Unsure
Do you have a seizure disorder?
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Yes
No
Unsure
Are you receiving cancer treatment or expecting surgery soon?
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Yes
No
Unsure
Allergies and prior IVs
Any allergy to medicines, vitamins, supplements, or foods?
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Yes
No
Unsure
Any allergy to latex, adhesive, chlorhexidine, or other antiseptics?
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Yes
No
Unsure
Any previous reaction to an infusion or injection?
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Yes
No
Unsure
Any fainting, dizziness, or difficulty with needles or blood draws?
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Yes
No
Unsure
Any allergy or adverse reaction to hemp, CBD, or cannabinoids?
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Yes
No
Unsure
Medicines and recent substance use
Do you take any prescription medicines, over-the-counter medicines, vitamins, herbs, or supplements?
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Yes
No
Unsure
Current medicines and supplements: list name, dose, frequency, and recent changes. Write None only if you take none. Write Unsure if you do not know.
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In the past 24 hours, have you used alcohol, cannabis, CBD, sedating medicines, or any other substances?
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Yes
No
Unsure
If Yes or Unsure, describe what was used, the amount, and the last time used (Enter None if all No).
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Pregnancy and visit readiness
Are you pregnant or could you be pregnant?
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Yes
No
Unsure
Not applicable
Are you breastfeeding?
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Yes
No
Unsure
Not applicable
Are you trying to become pregnant?
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Yes
No
Unsure
Not applicable
Have you eaten in the past 2–3 hours?
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Yes
No
Not yet—completing before visit
Blood, metabolic, and immune details: describe each Yes or Unsure answer, including dates, treatment and current status. Enter None if none.
*
Have you had fluids in the past 2–3 hours?
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Yes
No
Not yet—completing before visit
Have you recently been hospitalized, had surgery, or been advised not to receive IV treatment?
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Yes
No
Unsure
Should any arm not be used for IV placement due to dialysis access, lymphedema, or clinician instruction?
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Yes
No
Unsure
Optional cannabinoid discussion
Do you have liver-related concerns or abnormal liver tests?
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Yes
No
Unsure
This section gathers safety information only; it does not establish availability, approval, or suitability of a cannabinoid infusion.
Could cannabinoid drug testing affect your work or other obligations?
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Yes
No
Unsure
Have you ever had a reaction or concern after using a cannabinoid product, including excessive sleepiness, confusion, dizziness, nausea, or other symptoms? Enter None if all No.
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If you feel drowsy or impaired after treatment, will you have safe transportation?
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Yes
No
Unsure
Not applicable
Allergy and prior-reaction details: describe each Yes or Unsure answer above, including trigger, reaction, severity and treatment. Enter None if none.
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Does your treatment discussion include PICO IV, Core-A, CBD, or another cannabinoid product?
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Yes
No
Unsure
Previous cannabinoid products used and any reactions (enter None or Unsure if applicable).
Pregnancy and readiness details: explain any questions from above that you answered Yes or Unsure to for a health concern, hospitalization, surgery, or arm restriction. Enter None if none.
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Attestation
Attestation
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I have answered accurately to the best of my knowledge and will tell the clinician about changes before treatment. I understand this form does not clear me for an infusion and is not treatment consent.
Patient electronic signature
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Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Representative name and relationship (if completed by a representative)
First Name
Middle Name
Last Name
Submit for Clinician Review
Submit for Clinician Review
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