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Your Health Profile

Help us to understand more about you, your goals, and your health. Your input is confidential and will not be shared outside of the health professionals working on your session.

Date of Birth
Day
Month
Year
Requested IV Therapy

Medical Background

7. Have you ever been told that you have an electrolyte imbalance or other abnormal labs?
8. Do you currently have any heart problems?
Yes
No
9. Have you ever had heart problems?
Yes
No
11. Do you currently have any kidney problems?
Yes
No
12. Have you ever had kidney problems?
Yes
No
14. Have you ever been diagnosed with any of the following conditions?
16. Do you have any of the following allergies?
19. Do you smoke?
No
Yes, regularly
Yes, occasionally
20. Have you recently used recreational drugs?
No
Yes
21. Are you pregnant, trying to become pregnant, or nursing?
Pregnant
Trying to become pregnant
Nursing
No, none of these
22. When was your last IV drip of any kind?
This is my first time
Within the past 14 days
More than 14 days ago
23. When was your last iron IV drip?
This is my first time
Within the past 14 days
More than 14 days ago

I understand and acknowledge that:

  • I have been provided information about the IV therapy treatment, including its purpose, the substances to be administered, and the expected benefits.

  • I have been informed of potential risks and side effects, including but not limited to: pain or bruising at the injection site, infection, allergic reactions, phlebitis, and other complications. I understand that serious adverse reactions, while rare, are possible.

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