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Client Health History 

Please fill out the following form in order to determine eligibility for services

EMERGENCY CONTACT

Why are you seaking IV hydration?
Are you currently pregnant
Do you have any allergies to food or medicaton?

Do you have any of the following medical conditions?

❑ Angina

❑ Kidney disease

❑ HIV/AIDS

❑ Heart problems

❑ Kidney stones

❑ Congestive Heart Failure

❑ Cirrhosis of the Liver

❑ Edema

❑ Goiter

❑ Emphysema

❑ Hepatitis

❑ Cancer 

❑ Stroke

❑ Stomach  or peptic ulcer

❑ Leukemia

❑ Epilepsy (seizures)

❑ Rheumatic fever

❑ Psoriasis

❑ Cataracts

❑ Tuberculosis

​

❑ Diabetes

❑ Heart murmur

❑ Crohn’s disease

❑ High blood pressure

❑ Pneumonia

❑ Colitis

❑ High cholesterol

❑ Pulmonary embolism

❑ Anemia

❑ Hypothyroidism

❑ Asthma

❑ Jaundice

SELECT ONE
I ATTEST THAT I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS
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