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Medication-assisted
Weight Loss
About
Hydrafuse
IV Hydration
Services
IV Products &
Pricing
IV Hydration
FAQs
Contact
Our Team
Start Losing Weight
Complete the Medical History Form
Please provide or update your medical history here.
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Patient Contact Information
Name
(Required)
First
Last
Email
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Date of Birth
(Required)
Month
Day
Year
Gender
(Required)
Male
Female
Address
(Required)
Street Address
Address Line 2
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
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Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Occupation
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Medical History
Are you pregnant or breastfeeding?
Yes
No
Have you ever been told you have an electrolyte imbalance or other abnormal lab results?
Yes
No
If you answered yes, please check any conditions that apply:
Hypermagnesemia (high magnesium levels)
Hypercalcemia (high calcium levels)
Hypokalemia (low potassium levels)
Hemochromatosis (high iron levels)
Other
If you checked "Other," please specify the medical condition or lab result
Are you diabetic?
(Required)
Yes
No
Do you smoke?
(Required)
Yes
No
How much do you smoke?
How many alcoholic drinks do you consume in a week?
Do you use any recreational drugs?
(Required)
Yes
No
If you anwered yes, which recreational drugs do you use?
Do you use any diuretics or water pills?
(Required)
Yes
No
If you answered yes, please specify the diuretics or water pills you take
Are you currently taking any steroids (e.g. Prednisone?)
(Required)
Yes
No
If you answered yes, please list the steroids you are currently taking
Are you allergic to any medications or food?
(Required)
Yes
No
If you answered yes, please list your allergies and note their severity
Do. you have any of the following conditions (check all that apply)
Blood pressure (high or low)
Heart problems
Stroke or mini-stroke
Kidney problems
Kidney stones
Asthma
Optic nerve atrophy or Leber's Disease
Sickle cell anemia
G6PD Deficiency
Sarcoidosis
Parathyroid problems (high calcium levels)
Prescription Drug Use, Over-the-Counter Medications and Surgical History
Prescription medication #1
Dosage/Frequency
Prescription medication 2
Dosage/Frequency
Prescription Medication 3
Dosage/Frequency
Prescription Medication 4
Dosage/Frequency
Prescription Medication 5
Dosage/Frequency
Prescription Medication 6
Dosage/Frequency
Please list any over-the-counter medications, vitamins or supplements you are currently taking, along with their strength/dosage and frequency:
Please list any other medical conditions you have that are not mentioned above
Have you ever had any surgeries?
(Required)
Yes
No
if you have undergone any surgeries, please list the procedures and approximate dates
is there other relevant medical information you would like our nurse and physician to know?
Signature
(Required)
Date
(Required)
Month
Day
Year
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Comments
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