IV (Intravenous) Therapy Intake Form
Patient Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
N/A
Occupation
What is the motivation behind your interest in receiving IV Therapy?
Have you received IV Therapy before?
Yes
No
What was your experience like?
Can you provide a list of health conditions or medical concerns to be evaluated for the potential benefits of IV Therapy?
Fatigue
Low Depressed Mood
Anemia
Weight Issues
Irritability/Moodiness
Trying to get Pregnant/Fertility Prep
Stress
PMS
Allergies
Sleep Disorders
Asthma
IBS/Inflammatory Bowels
Low Immunity
Digestive Issues
Numbness/Tingling of the body
Migraines
Muscle Spasms
Aging
Other
Please check if you have any of the diagnoses below
High Blood Pressure
Arrhythmia
Abnormal EKG
CHF
Low Blood Pressure
Angina
MI / Heart Attack
Diabetes
Bleeding Disorder
Ankle Swelling
Kidney Disease
Asthma
G6PD Deficiency
Anxiety
Congestive Heart Failure
Edema
Sudden Weight Loss
Cancer
Other
Date of last Physical Exam/Blood Test
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Results of the test
Provide a list of all known and suspected allergies
Please list all current and past medical conditions, diagnosis, hospitalizations, surgeries
Please provide a comprehensive list of all the prescription drugs and supplements you are presently taking, including their respective doses.
Over the last 2 weeks, how often have you been bothered by the following problems?
Rows
Not at all
Several days
More than half the days
Nearly everyday
Feeling nervous, anxious, or on edge
1
2
3
4
Not being able to stop or control worrying
5
6
7
8
Little interest or pleasure in doing things
9
10
11
12
Feeling down, depressed, or hopeless
13
14
15
16
How did you hear about us?
Additional notes
Submit
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