Medical Waiver


Date: ___/___/_____



MEDICAL INTAKE FORM


Name: _____________________ DOB: ___/___/_____


Address: ___________________ Email: ________________________

___________________________

___________________________ Referred by:  ___________________



Past Medical History:___________________________________________________________

_________________________________________________________________

 

Arthritis Kidney Disease Cancer

Diabetes Headaches Allergies/Asthma

Heart Condition Anxiety/Depression High Blood Pressure

Stroke History Organ Transplant Neurological Problems

COPD Insomnia Dizziness

Infectious Disease Fatigue Pregnancy

Congestive Heart Failure Bipolar Disorder Hepatitis / HIV

 

Past Surgical History:___________________________________________________________

 

Medications:_______________________________________________________

_________________________________________________________________

 

Allergies:_________________________________________________________

 

Social History:  Tobacco Abuse: Y / N    Alcohol Use:  Y / N Drug Use:  Y / N

 

Do you feel you are in good health:  Y / N

 

Have you passed out giving blood in the past:  Y / N

 

Do you have any health concerns today that you would like to mention: Y / N

______________________________________________________________________________

 

Vitals:  HR: ____  BP:____/____   Temp: _____ RR:______ POx:  ______%

 

No life threatening, signs or symptoms that would be felt to prevent the patient from receiving IV therapy?  Y /N

 

Signature:

 

Date: