Welcome, IV Hydration Therapy patients! Medical HistoryPlease fill out the form below Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Your Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Current Medications: Last Set of Labs: Enter Test Type & Date Presence of Edema? Yes No Past Medical History Have you ever been diagnosed with (check all that apply) Hypertension Angina/Chest Pain Swelling Arrhythmia Congestive Heart Failure MI (Heart Attack) Abnormal EKG Kidney Disease Fluid Retention of unknown etiology Sudden weight loss Diabetes Anxiety/Panic Attack G6PD Leber’s Disease Liver Disease Cancer Blood/bleeding disorder Females: Could you be pregnant? Yes No Allergic To: Latex Shellfish Iodine Cobalt Vitamins Dye/Food Preservatives Gluten Milk Contraindicated: Which IV Hydration/Nutrition Therapy Do You Want? Alleviate Reboot Brainstorm Get Up And Go Immunity Performance and Recovery Inner Beauty Myer's Cocktail Quench Thank you!
