DHHH IV Infusion Therapy – Intake Form – RIVT

DHHH IV Infusion Therapy - Intake Form - RIVT

Full Name

Address

City

State

Zip Code

Date of Birth

Age

Sex

Male

Female

Emergency Contact

Phone/Mobile

Relationship

Other

Do you have any of the following conditions?

	Yes	No
Blood pressure problems (high or low)
Heart Problems
Stroke or “mini stroke"
Kidney problems
Kidney Stones
Asthma
Optic nerve atrophy or Leber's Disease
Sickle Cell Anemia
G6PD Deficiency
Sarcoidosis
Parathyroid problems (high levels)
Are you a diabetic?

Are you a smoker

Yes

If so, how much per day?

List any other medical condition you have (not mentioned above):

How many alcoholic drinks do you consume in one week?

Do you use any recreational drugs?

Yes

If so, which ones and how often?

Prescription medications, strength dosage, condition being treated:

Over the counter medications including vitamins and other supplements:

List all surgical procedures you have had with the approximate dates:

How did you hear about us?

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Date