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Home
About Us
GLP-1 Injections
Weight Loss
- Svelte Rx Classic Weight Loss Program
Pricing
Telehealth
Testosterone/Hormone Therapy
Contact

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IV Hydration Medical History Form

Date

Name

Phone

Email

Date of Birth

Allergies

Current Medications

1. Have you ever had prior IV nutrient infusion?

No Yes

If so, when

Did you have problems with prior infusions including reactions, allergies, or access issues?

2. Do you have any of the following conditions?

None End Stage Renal Disease Cerebral Hemorrhage Hyperparathyroidism Congestive Heart Failure (CHF) Myasthenia Gravis Hypermagnesium Kidney/Renal Disease Hemolytic Anemia Current UTI Cardiac Arrhythmia Low Blood Pressure Kidney Stones Liver disease

3. Have you been told that you need to start dialysis or are you currently on dialysis?

Yes No

4. Are you taking or have you been told you need to take Digoxin?

Yes No

5. Have you been told you have a decreased GFR or kidney problem?

Yes No

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