Patient Medical History and Intake Form

Date: __________________________

Name: ____________________________________________________________

DOB:____________________    Age: ________

Address: __________________________________________________________________

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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?

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Allergies (Medications, foods, etc.) Are you allergic to sulfa drugs? Eggs?

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Current Medications: (Please include OTC & supplements)

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Please check any conditions that apply to you:

 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

 Acid Reflux                 Liver Disease

 Bladder Disease           Hepatitis A, B, C

 Kidney Disease            Other _________________________

 Hyper/Hypo Thyroid             Rheumatoid Arthritis

 Diabetes Type I Type II         Hx of Diabetic ketoacidosis

 Lupus                                   Other ______________________

 Stroke/TIA

 Multiple Sclerosis     Parkinson’s

 Seizures – date of last seizure _______________     Alzheimer’s

 Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell)

 MTHFR polymorphism

 G6PD Deficiency

 Back Pain                             Degenerative Joint Disease

 Carpal Tunnel Syndrome       Degenerative Disk Disease

 Fibromyalgia                         Other_________________________

 Depression

 Anxiety or Panic Attacks

 Suicidal Ideations

 Location of Cancer _____________________________

 Chemotherapy

 Radiation

 Hormone or Biological Therapy

WOMEN (non-menopausal)

Last Menstrual Period ________________________

Any Chance You Are Pregnant? ______________

Are You Currently Breastfeeding? ________________

 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.?

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Would you like to tell us anything else that you feel like is important?

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I attest that the information I have provided is true and accurate to the best of my knowledge:

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Signature                                                                           Date

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