660 IV Health Intake Questionnaire Today's Date(Required) MM slash DD slash YYYY Name(Required) First Last Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Reason for visit:(Required) Emergency ContactName(Required) First Last Name of emergency contactRelationship(Required) Relationship to emergency contactPhone(Required)Phone number of emergency contactPlease 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?(Required)Allergies (Medications, foods, Etc.):Current Medications: (Please include OTC & Supplements)Please check any conditions that apply to you:CARDIOVASCULAR AND RESPIRATORY High Blood Pressure Heart Murmur Valve Disorder Abnormal Rhythm Chest Pain Heart Attack Cardiac Surgery or Stents Congestive Heart Failure Peripheral Artery Disease Thrombosis or DVT Aneurysm Asthma COPD Sleep Apnea Shortness of Breath Pulmonary Hypertension Other Lung Disorder Other Cardiac Disorder GASTROINTESTINAL AND URINARY Acid Reflux Bladder Disease Kidney Disease Liver Disease Hepatitis A, B, C Other Please Explain METABOLIC/ENDOCRINE/AUTOIMMUNE Hyper/Hypo Thyroid Diabetes Type I Type II Lupus Rheumatoid Arthritis Hx of DKA Other Please Explain HEMATOLOGY Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell) G6PD Deficiency(glucose-6-phosphate dehydrogenase) G6PD Deficiency(glucose-6-phosphate dehydrogenase) NEUROLOGIC Stroke/TIA Multiple Sclerosis Parkinson’s Alzheimer’s Seizures Date of Last SeizureMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HEMATOLOGY Anemia (Iron Deficiency, Pernicious, Aplastic, Hemolytic, Sickle Cell) MTHFR (methylenetetrahydrofolate reductase gene) G6PD Deficiency (glucose-6-phosphate dehydrogenase) MUSCULOSKELETAL Back Pain Carpal Tunnel Syndrome Fibromyalgia Degenerative Joint Disease Degenerative Disk Disease Other Please Explain PSYCHOLOGICAL Depression Anxiety or Panic Attacks Suicidal Ideations CANCER Chemotherapy Radiation Location of Cancer Women(non-menopausal)Last Menstrual PeriodMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Any chance you are pregnantNAYesNoAre you currently breastfeeding?NAYesNoPain CRPS (Complex Regional Pain Syndrome) Fibromyalgia Do you drink alcohol, use any tobacco, or substance use? 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?SignatureDate MM slash DD slash YYYY Print Name Better Health Care is Our Mission 24/7 service. Same Day Appointments are Available. (660)339-6006 660ivhealth@gmail.com Book an Appointment Today!
