DropFusionIV Patient Questionnaire
Date of Birth
Past Medical History
High Blood Pressure
Heart Disease (please specify below)
Do you currently have any of the following symptoms?
Fevers (measured or not)
Shortness of breath
Recent contact with anyone with COVID or flu-like symptoms
None of the above
All surgical procedures you have had with approximate dates
Supplements/Vitamins/Over the Counter medications
Are you pregnant or breastfeeding?
What are your main complaints?
Fatigue or low energy
Poor diet due to busy lifestyle
Cold or Flu symptoms
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
Is there anything else that you would like our staff to know?
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