DropFusionIV Patient Questionnaire
* Required
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Email
*
Your answer
Phone number
*
Your answer
Past Medical History
*
None
High Blood Pressure
Heart Disease (please specify below)
Kidney Stones
Stroke
Diabetes
Leber's Disease
G6PD Deficiency
Other:
Required
Do you currently have any of the following symptoms?
*
Fevers (measured or not)
Body aches
Cough
Shortness of breath
Headache
Sore throat
Recent contact with anyone with COVID or flu-like symptoms
None of the above
Required
All surgical procedures you have had with approximate dates
Your answer
Prescription Medications
Your answer
Supplements/Vitamins/Over the Counter medications
Your answer
Allergies
Your answer
Are you pregnant or breastfeeding?
*
No
Yes
What are your main complaints?
Fatigue or low energy
Stress
Trouble concentrating
Poor diet due to busy lifestyle
Cold or Flu symptoms
Dehydration
Hangover relief
Other:
Which statements best describe why you are here today?
I want more energy and to feel better overall
I want to do everything I can to nourish my body
I want to enhance my weight loss efforts
I want to avoid getting sick
I want faster recovery from injury or illness
I want to slow the aging process
I want to feel and look younger
I want smoother, brighter and more vibrant skin
I want to cleanse my body of toxins
I want to recover quickly from a hangover
Other:
Is there anything else that you would like our staff to know?
Your answer
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