Patient Medical History and Intake Form

Patient Medical History and Intake Form

List view
Operations
1.0 Pre-Launch
1.0 Pre-Launch - 01 Documentation
1.0 Pre-Launch - 02 DLC Partners & Stakeholders
1.0 Pre-Launch - 03 Site Audit & Survey
1.0 Pre-Launch - 04 Systems & Processes
2.0 Launch
2.0 Launch - 01 Presentations & Proposals
2.0 Launch - 02 Menus & Marketing Material
2.0 Launch - 03 Vendor Forms & Information
2.0 Launch - 04 SOPs & Protocols
2.0 Launch - 05 Staffing & Onboarding
2.0 Launch - 06 Operational Systems & Software
3.0 Active Operations
3.0 Active Operations - 01 Documentation
3.0 Active Operations - 02 Vendors Inventories & Quotes
3.0 Active Operations - 03 Menus Brochures & Printed Collateral
3.0 Active Operations - 04 SOPs & Protocols
3.0 Active Operations - 05 Staffing
3.0 Active Operations - 06 Operational Equip. & Programs
3.0 Active Operations - 07 Presentations & Proposals

Patient Medical History and Intake Form

Discovery Well Being Infusion Lounge & Injection Bar
Date: __________________________
Name: ____________________________________________________________
DOB:____________________    Age: ________
Address: __________________________________________________________________
__________________________________________________________________
Phone: ____________________Email: __________________________________
Reason for visit: __________________________________________________________________
Emergency Contact: __________________________________________________________________
Please briefly describe why you are seeking IV infusion or injection therapy? For example: Are you looking to improve your energy, skin/hair/nail quality, recovery times, immune system, or hydration status? Are you seeking treatment for a hangover or looking to feel and look better?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Allergies (Medications, foods, etc.) Are you allergic to sulfa drugs? Eggs?
______________________________________________________________________________________________________________________________________________________________________________________________________
Current Medications: (Please include OTC & supplements)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please check any conditions that apply to you:
CARDIOVASCULAR AND RESPIRATORY
 High Blood Pressure              Asthma
 Heart Murmur                        COPD
 Valve Disorder                       Sleep Apnea
 Abnormal Rhythm                 Shortness of Breath
 Chest Pain                              Pulmonary Hypertension
 Heart Attack                           Lung Cancer
 Cardiac Surgery/Stents          Other Lung Disorder _____________________
 Congestive Heart Failure       Other Cardiac Disorder ___________________
 Peripheral Artery Disease
 Thrombosis or DVT
 Aneurysm
GASTROINTESTINAL AND URINARY
 Acid Reflux                 Liver Disease
 Bladder Disease           Hepatitis A, B, C
 Kidney Disease            Other _________________________
METABOLIC/ENDOCRINE/AUTOIMMUNE
 Hyper/Hypo Thyroid             Rheumatoid Arthritis
 Diabetes Type I Type II         Hx of Diabetic ketoacidosis
 Lupus                                   Other ______________________
NEUROLOGIC
 Stroke/TIA
 Multiple Sclerosis     Parkinson’s
 Seizures – date of last seizure _______________     Alzheimer’s
HEMATOLOGY
 Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell)
 MTHFR polymorphism
 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
 Hormone or Biological Therapy
WOMEN (non-menopausal)
Last Menstrual Period ________________________
Any Chance You Are Pregnant? ______________
Are You Currently Breastfeeding? ________________
PAIN
 Chronic regional pain syndrome
 Headaches/Migraines
 Musculoskeletal Pain
 Nerve Pain
Do you drink alcohol or use recreational drugs? If so, please explain: ______________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever had an electrolyte or fluid imbalance in the past? Such as low potassium, high sodium, etc.?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Would you like to tell us anything else that you feel like is important?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I attest that the information I have provided is true and accurate to the best of my knowledge:
__________________________________________________________________
Signature                                                                           Date
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