IV Therapy and Vitamin Injections

General Health Questions:

Please describe your current health status:

Excellent
Good
Fair
Poor

Do you have any allergies, especially to medications or supplements?

Yes
No

Please specify medications/supplements

Are you currently taking any medications?

Yes
No

Please include both prescription and over-the-counter:

Have you had any previous reactions to IV therapy or injections?

Yes
No

Are you currently pregnant or breastfeeding?

Yes
No

Medical History:

Do you have any chronic illnesses or health conditions?

Yes
No

Please specify

Have you recently undergone any surgeries or medical procedures?

Yes
No

Please provide details

Do you have a history of heart, kidney, or liver disease?

Yes
No

Lifestyle Information:

What is your main reason for seeking IV therapy and vitamin injections?

Yes
No

(e.g., improved wellness, immune support, athletic performance)

Describe your typical daily diet:

How often do you exercise?

Daily
Several times a week
Once a week
Rarely or never

What types of exercise do you engage in?

Jogging
Swimming
Cycling
Weightlifting or resistance training

Do you use tobacco, alcohol, or recreational drugs?

Yes
No

Please specify frequency and type

Daily - tobacco, Once a week - Alcohol

Treatment Expectations and Preferences:

What are your specific goals or expectations from receiving IV therapy and vitamin injections?

Boosting energy and vitality
Enhancing athletic performance
Replenishing essential nutrients
Managing stress and promoting relaxation

Have you received IV therapy or vitamin injections before?

Yes
No

What was your experience?

Are there specific vitamins or minerals you are particularly interested in?

Yes
Not at the moment

Please specify

Are you interested in proactive healthcare and preventative measures to optimize your health and longevity?

Yes
No

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Yes
No

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Yes
No

How much do you budget for your wellness each year?

Less than $1000
Less than $10,000
More than $10,000

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

If you heard about us from another source, please specify.

Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations