Medical Questionnaire

Please fill out the form below if you are interested in IV Therapy, and one of our representatives will contact you soon to schedule an appointment. Please call (866) 944-8253 if you have any questions.

Name
Address
Email
Date of Birth
Phone
Requested Appointment Date
Requested Appointment Time
Allergies
Please list anything you are allergic to (medications, food, etc). If none, please type "none".
Medications (Prescriptions)
Names of prescriptions, strength and frequency
Medical History  Diabetes Mellitus Type I Diabetes Mellitus Type II (Adult Onset) Hypo/Herthyroidism Asthma COPD/Emphysema Hypertension Congestive Heart Failure Coronary Artery Disease / Chest Pain History of Heart Attack Shortness of Breath Edema (Arm or Leg Swelling) Chronic Nausea / Vomiting Liver Problem Kidney Problem incl. Kidney Stones Hepatitis B or C Positive Constipation/Diarrhea Inflammatory Bowel Disease Irritable Bowel Syndrome History of Stroke History of Blod Clot or DVT Enlarged Prostate

Any type of cancer (please specify type):
Any Additional Medical Problems
Surgical History  Brain surgery Cataract surgery Tonsillectomy Angioplasty / Heart Bypass Gall Bladder Surgery Appendectomy Joint Replacement Surgery Joint Surgery Hernia Surgery Hysterectomy (complete / partial) C-Section Mastectomy Prostate Surgery

Please list any additional surgeries:

Review of Symptoms

Please select the symptoms you are experiencing. These symptoms are pertinent to patients receiving intravenous therapy.

General  Weakness Fatigue Dehydrated Fever Chills
Head and Neck  Headache Dizziness Sinus Pain and Discharge Sore Throat Ear Pain
Pulmonary  Coughing Wheezing Sputum Production Shortness of Breath Coughing up Blood
Cardiovascular  Chest Pain Shortness of Breath with Exertion Arm or Leg Swelling Trouble Breathing when Lying Down Leg Pain (muscles) when Walking History of Heart Disease History of Heart Failure Heart Murmur
Gastrointestinal  Nausea Vomiting Abdominal Enlargement Abdominal Pain Rectal Bleeding Constipation / Diarrhea Previous Jaundice History of Liver Failure Ascitis (fluid in the abdomen)
Genitourinary  Incontinence Problem with Prostate Pain with Urination Frequency of Urination Blood in the Urine
Neurological  Fainting Seizures Abnormal Gait Paralysis
Endocrine  Goiter or Thyroid Trouble Diabetes Increased Thirst Frequent Urination
Blood / Lymphatic  Anemia Bleeding Tendency Clotting Problems Enlarged Lymph Node Easy Bruising
Musculoskeletal  Muscle Cramps Muscle Weakness Pain in the Joints Swollen Joints

Or Download Form

If you prefer not to fill out the form online, you may download, print, and fill out our Medical Questionnaire to bring with you to your first appointment.

Download Questionnaire