N2 Medical History Intake and Consent Form

Intake & Consent
General Information
Full Name*
First NameLast Name
Birth Date*
MonthDayYear
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
E-mail*
Phone Number*
Area CodePhone Number
Gender
How did you hear about us?
ex; Facebook, my doctor, a friend
Services Requesting*
Services include: Infusion, Injectable, Compression , or any Combination
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.*
Although it is not required we highly recommend that you are under the care of a healthcare professional who will continue to monitor any medications and any health concerns that you list here*
I acknowledge
What medications, supplements and over the counter items do you take regularly or are currently prescribed:*
Any past surgeries and hospitalizations?*
Diet and lifestyle
Do you regularly drink alcoholic beverages?
If yes, how many per week?
Do you smoke tobacco?
Do you use recreational drugs?
Please list any food allergies, intolerances or foods you avoid and the reason.
Health History

Health History*

	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Depressive symptoms
Anxiety
Thyroid problems
Diabetes
Blood sugar irregularities
Headache
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Constipation
Diarrhea
Liver problems
Kidney problems
Irregular Heartbeat
Are you pregnant
Epilepsy / Seizures
Cancer

What are your top preferences for checking in?
Top choice Works ok Doesn't work for me
Morning (9am-noon)
Afternoon (1 pm-5pm)
Evening (after 5pm
I have read the following documents, fully understand them and agree to their terms (please sign with your cursor below). *
Clear
Should be Empty:

Intake & Consent