Patient History Form

Personal Information

First Name*

Last Name*

Your Age*

Date of Birth*

Gender*

Contact Information

Phone Number*

Email Address*

Street Address*

Street Address (cont)

City*

State*

Zip Code*

Medical History

Please List Any Allergies You Have:*

Are you currently taking any medications? If so, please specify or say none.*

Are you under the care of a primary physician?*

Yes

No

If yes, include the name and phone number of your doctor:

Conditions

Do you have any of the following conditions?

Kidney/Renal Disease*

Yes

No

Myasthenia Gravis*

Yes

No

Myxedema*

Yes

No

Hepatitis*

Yes

No

Cerebral Hemorrhage*

Yes

No

Hypermagnesium*

Yes

No

Cancer*

Yes

No

COPD/Respiratory*

Yes

No

Hyperparathyroidism*

Yes

No

Seizures/Epilepsy*

Yes

No

Cardiac Arrhythmia*

Yes

No

Mental Illness*

Yes

No

G6PD Deficiency*

Yes

No

Hemolytic Anemia*

Yes

No

High or Low Blood Pressure*

Yes

No

HIV*

Yes

No

Congestive Heart Failure*

Yes

No

Diabetes*

Yes

No

Please let us know any other conditions not listed above:

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

Yes

No

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

Yes

No

Are you of African, Middle Eastern or Asian descent? (G6PD screening for Vitamin C infusion)*

Yes

No

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

Yes

No

Do you have an implanted medical device or defibrillator?*

Yes

No

What is your purpose for coming to New Spring Wellness or how can we help you?*

Submit