What do you believe is causing your most important health concern?

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Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to send you email confirmations for your appointments as well as The IV Wellness Boutique Inc. specials and newsletter. Other Health Care Providers Name Profession Phone Name Profession Phone Health information List your health concerns (physical, emotional or psychological) in order of importance to you, and the date your symptoms began: 1. Date 2. Date What do you believe is causing your most important health concern? 1

Allergies and sensitivities List all allergies to medications, environment and food: 1. Reaction 2. Reaction 3. Reaction 4. Reaction Supplements and medications List all supplements you are currently taking: Supplement Daily Dose How Long Reason List all medications you are currently taking: Medication Daily Dose How Long Reason Are the medications well tolerated? Yes No If no, what are the adverse reactions? Medication Reaction 2

Medical history List any condition that you have been diagnosed with: 1. Date 2. Date 3. Date 4. Date Indicate if you have had any of the following diagnostic tests performed: Notable Finding Notable Finding Thyroid Panel Complete Blood Count Blood Sugar Test Colonoscopy Cholesterol EKG Chest X-Ray Mammography List any past surgeries, hospitalizations, injuries (broken bones, joint sprains, burns, falls, car accidents etc.) or dental work (root canal, mercury or ceramic fillings, implants, caps, dentures etc.): 1. Date 2. Date 3. Date 4. Date 3

5. Date 6. Date 7. Date 8. Date 9. Date 10. Date Women s health Check all of the symptoms that apply to you: hot flashes vaginal dryness breast tenderness mood swings bloating night sweats irritability/impatience headaches cramping clots Men s health Check all of the symptoms that apply to you: urinary pain urinary urgency urinary hesitancy low libido hernia prostate problems discharges/sores sexual difficulties testicular mass/pain: Date of last prostate exam (if applicable): 4

Family history Indicate whether any family members have had any of the following: Relation To You Relation To You Alcoholism Allergies Alzheimer s Disease Arthritis Asthma Cancer (indicate type) Diabetes Drug Abuse Heart Disease High Blood Pressure Kidney Disease Osteoporosis Depression Other Illnesses Stroke Thyroid Condition 5

Symptom review Check all symptoms occurring presently or within the past 6 months General recent weight change cold intolerance health intolerance daytime sleepiness early waking insomnia fatigue fever Head / Eyes / Ears headache / migraines ear pain ear buzzing / ringing changes in hearing itchy / watery eyes changes in vision eye pain Musculoskeletal low back pain foot cramps / pain joint deformity joint pain / stiffness muscle pain muscle weakness muscle spasms/cramps tendonitis TMJ problems tension headaches Skin / Nails acne (face / torso) athlete s foot/jock itch dandruff bumps on arms cellulite dark circles under eyes 6

lack of sweating sweating easily eczema / hives / rash psoriasis oily skin itchy skin dry skin suspicious moles changes in pigment skin darkening hair loss ridging / spots on nails soft nails thickening of nails Gastrointestinal bloating constipation diarrhea blood or mucus in stool pain with stool cramps / indigestion flatulence belching acid reflux haemorrhoids anal fissures undigested food in stool food intolerances jaundice nausea Respiratory breathlessness exercise intolerance dry cough productive cough hoarseness seasonal allergies nasal congestion snoring wheezing / asthma sore throat Cardiovascular chest pain / angina heart palpitations irregular pulse easy bruising varicose veins swollen ankles / feet 7

high blood pressure cold hands and feet Urinary UTI frequent urination incontinence / dribbling discomfort on urination blood in urine Lymph / Immune System enlarged lymph nodes painful / tender nodes swelling of extremities frequent infections slow wound healing Mind / Nervous System anxiety depression irritability / impatience difficulty concentrating poor memory fearful / chronic worry panic attacks numbness / tingling speech difficulty seizures tremor / trembling dizziness / vertigo light headed / fainting loss of balance Eating / Appetite can t gain weight can t lose weight frequent dieting poor appetite always-hungry emotional eater salt cravings carbohydrate cravings sugar cravings caffeine-dependent binge eating bulimia / anorexia 8

o What would you like to gain from today s visit? Did someone refer you? How did you hear about the IV? Would you like to receive our newsletter for the latest news and gift offerings? Indicate on the figure below any areas of concern: 9

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