Medical History Form Please fill out this form prior to your appointment. Today's Date MM slash DD slash YYYY BASIC INFORMATION:Name First Last Date of Birth MM slash DD slash YYYY Gender PLEASE LIST ANYTHING THAT YOU ARE CURRENTLY TAKING:ALLERGIES (MEDICATION, FOOD, OR OTHER):CURRENT MEDICATIONS:VITAMINS AND/OR SUPPLEMENTS:SOCIAL/MEDICAL HISTORY:ARE YOU A SMOKER? Yes No DO YOU DRINK ALCOHOL? Yes No HOW MANY ALCOHOLIC DRINKS IN A WEEK?DO YOU USE ANY RECREATIONAL DRUGS? Yes No WHICH ONES AND HOW OFTEN?HAVE YOU BEEN EXPOSED TO SOMEONE WHO HAS TESTED POSITIVE FOR COVID19? Yes No PERTINENT MEDICAL HISTORY:DATE OF LAST CHEMISTRY OR LAST SCREENING? MM slash DD slash YYYY HAVE YOU EVER BEEN TOLD THAT YOU HAVE AN ELECTROLYTE IMBALANCE? Yes No ARE YOU PREGNANT OR BREASTFEEDING? Yes No ARE YOU DIABETIC? Yes No ARE YOU TAKING DIGOXIN OR DIURETICS FOR ANY HEART PROBLEMS? Yes No DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS? (A DIAGNOSIS OR TOLD YOU HAVE…) ANXIETY OR DEPRESSION HIGH BLOOD PRESSURE HEART PROBLEMS STROKE OR “MINI” STROKE KIDNEY PROBLEMS (KIDNEY STONES, RENAL FAILURE, DIALYSIS, ETC;) LIVER DISEASE ASTHMA ALLERGIES MIGRAINES OR HEADACHES CHRONIC FATIGUE OR FIBROMYALGIA SICKLE CELL ANEMIA G6PD DEFICIENCY (SCREENING FOR VIT. C INFUSION) AFRICAN, ASIAN, OR MIDDLE EAST DESCENT? THYROID PROBLEMS MYASTHENIA GRAVIS PARKINSON’S ANY OTHER MEDICAL CONDITION NOT LISTEDANY SURGERIES OR SURGICAL PROCEDURESHAVE YOU EVER HAD IV NUTRITION? Yes No WHEN /WHAT FOR?ANY PROBLEMS WITH PRIOR IV INFUSIONS? (REACTIONS, ALLERGIES, OF IV ACCESS)WHAT WOULD BE YOUR OPTIMAL GOAL OF TREATMENT?IS THERE ANYTHING ELSE THAT YOU WOULD LIKE OUR HEALTH PROFESSIONALS TO KNOW?
