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
