IV Treatments
Conditions
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Pre IV Questionnaire

IV Treatments
Conditions
Contact Us
Schedule Appointment
Pre IV Questionnaire

IV Treatments
Conditions
Contact Us
Schedule Appointment
Pre IV Questionnaire

Pre IV Questionnaire

Pre IV Questionnairekarlgreif2021-10-20T02:46:27+00:00

Personal Information

Please complete your questionnaire and all consent forms completely.

Date of Birth *

How did you hear about us?

Friend or colleague

Radio / TV

Social Media

Google

Other

If other please specify:

Preferred Location *

Medical History

If not applicable, please type N/A in each box.

Please list your medical history - past and current. *

Please list any past surgeries. *

List any prescription medications you are currently taking. *

List any over-the-counter medications you are currently taking. *

List any vitamins and supplements you are currently taking. *

List any allergies or sensitivities you may have to vitamins or supplements *

Do you have any medication allergies or sensitivities? *

Do You...

Drink Alcohol?

Yes

Smoke Tobacco Products? *

Yes

Use Recreational Drugs? *

Yes

If you answered yes to any of the above questions, please explain how frequently *

Do you have any of the following conditions?

Congestive heart failure *

Yes

Heart block *

Yes

Unexplained significant swelling of the feet and legs *

Yes

Kidney failure or dialysis *

Yes

High calcium levels in blood *

Yes

Sarcoidosis *

Yes

Hemachromatosis (iron overload) *

Yes

Leber's Disease (hereditary optic nerve atrophy) *

Yes

History of fainting during blood draws or IVs *

Yes

Abnormal heart rhythms *

Yes

Uncontrolled high blood pressure *

Yes

Recurrent kidney stones *

Yes

Hyperparathyroidism *

Yes

Sickle Cell disease *

Yes

G6PD deficiency *

Yes

Hypersensitivity to cobalt *

Yes

Does your family have a history of the following conditions?

Hemachromatosis (iron overload) *

Yes

Sickle Cell disease *

Yes

G6PD deficiency *

Yes

Other conditions *

Yes

If you answered Yes to Other conditions above, please specify which conditions. *

Are you a male or female? *

Male

Female

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All information provided on the website or at one of our locations is not to be considered medical advice. We do not treat any medical conditions or otherwise. We provide nutritional IVs, Intramuscular Injections and other services as alternative methods to better our customers’ health and well being.

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