IV Nutrient Therapy Intake Form

Name(Required)
MM slash DD slash YYYY
What are your main complaints?(Required)
Check all that apply
Which statements best describe why you are here today?
Check all that apply

Medical History

Are you pregnant or breastfeeding?
Have you ever been told that you have an electrolyte imbalance or other abnormal labs?
Check all that apply
Are you a diabetic?(Required)
Are you a smoker?(Required)
Do you use any recreational drugs?

Please list everything you are currently taking:

Do you take Digoxin (Lanoxin) for a heart problem?(Required)
Do you take any diuretics or water pills?(Required)
Do you take any steroids, i.e. Prednisone?(Required)
Do you have any medication or food allergies?(Required)
Do you have any of the following conditions?

IV Nutrient Therapy Intake Form will be submitted to Sayana Medical Spa and Wellness Center