Client Health Form & Consent Form First Name *Last Name *Mobile Phone *Email AddressIntroduction & PurposeDate of Birth *Please enter your date of birthHow did you find out about us? *Choose oneGoogleFacebookInstagramReferred by a friendElsewhere on the internetI know one of the staffReferred by my health providerSomething elsePlease list any diagnosed illnesses you have, if anyPlease list any allergies you have, if any.Do you have any of the following conditions?Please check the box for any that applySleep problems (insomnia, difficulty falling asleep, etc.)Brain fogAfternoon fatigueGut health issues (bloating, constipation, diarrhoea, etc.)Skin problems (acne, dryness, eczema, etc.)Chronic painHeadaches/migrainesStress or anxietyDepression or mood swingsPoor concentration or memoryMuscle weaknessJoint pain or stiffnessFrequent colds or infectionsAllergies or sinus issuesHormonal imbalancesWeight gain or difficulty losing weightLow libidoHair loss or thinningFatigue after mealsFood cravingsDizziness or lightheadednessRapid heartbeat or palpitationsShortness of breathSeizures or epilepsyPlease list any goals you have in relation to your healthWhat is your best case scenario with IV therapy?Do you smoke or vape?Yes or NoYesNoPlease list any addiction issues you have, if any.How many times a week do you exercise? *Between 1-10, how would you rate your overall stress levels? *Do you have a history of seizures or epilepsy? *Choose oneYesNoPlease provide details (triggers, frequency, etc)Have you experienced any episodes of fainting? *Choose oneYesNoPlease provide details (triggers, frequency, etc)What vitamins/minerals are you currently taking, if any?What medication are you currently on, if any?Please provide any other relevant info about your healthEmergency Contact InfoFirst & Last Name *Phone #Email AddressFinish
