IV Center Health Questionnaire
Please fill out the information below to be approved for an IV
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Primary IV Center Location
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Erie, PA
Aspinwall, PA
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
*
example@example.com
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Medical History
Do you have any of the following?
Congestive Heart Failure
*
Yes
No
Heart Block
*
Yes
No
Unexplained Significant Swelling of the legs and feet
*
Yes
No
Kidney Failure or Dialysis
*
Yes
No
High Calcium levels in blood
*
Yes
No
Sarcoidosis
*
Yes
No
Hemochromatosis (iron overload)
*
Yes
No
Leber’s disease (hereditary optic nerve atrophy)
*
Yes
No
History of fainting with blood draws or IV
*
Yes
No
Abnormal Heart Rhythms
*
Yes
No
Uncontrolled High Blood Pressure
*
Yes
No
Recurrent kidney stones
*
Yes
No
Hyperparathyroidism
*
Yes
No
High calcium levels in blood
*
Yes
No
Sickle Cell Disease
*
Yes
No
G6PD deficiency
*
Yes
No
Hypersensitivity to cobalt
*
Yes
No
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Family History
Do you have a family history of?
Hemochromatosis (iron overload)
*
Yes
No
G6PD deficiency
*
Yes
No
Sickle Cell Disease
*
Yes
No
Other Conditions
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Women Only
Pregnant or breast feeding
Yes
No
First day of last menstrual period?
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Other Questions
Please list other medical conditions
*
Type "None" if you have no other medical conditions
Please list any surgeries
*
Type "None" if you haven't had any surgeries
Please list any allergies to medications
*
Type "None" if you have no allergies to medications
Please list current prescription medications
*
Type "None" if you have no prescription medications
Please list current over-the-counter medications
*
Type "None" if you have no over-the-counter medications
Please list current vitamins and supplements
*
Type "None" if you have no vitamins or supplements
Please list allergies or sensitivities to supplements or vitamins, particularly Vitamin C, B Vitamins, Magnesium, Calcium, Glutathione, Amino Acids, and GABA
*
Type "None" if you have no allergies or sensitivities
Do you drink alcohol?
*
Yes
No
If “yes”, how many drinks per week?
*
Do you smoke
*
Yes
No
If “yes”, how many per day?
*
Other recreational drug use amount and frequency
*
Type "None" if you don't use recreational drugs
How did you hear about us?
*
ie. A friend, TV / Radio Commercial, Facebook, Instagram, Google Search
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Waiver
Signature
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