Intake - Vital Force IV Therapy

Vital Force Therapy & Wellness Intake Form

Please list current symptoms & concerns prompting your visit
Additional symptom
Additional symptom
Additional symptom
Additional symptom
Additional symptom

Patient Information
FIRST NAME
MIDDLE NAME
LAST NAME
NICKNAME
ADDRESS
CITY
STATE
ZIP
HOME PHONE:
MOBILE PHONE:
EMAIL ADDRESS:
DRIVERS LICENSE NUMBER (copy required on checkin)
OCCUPATION:
HOURS PER WEEK:
REFERRED BY:
HEIGHT:
WEIGHT:
BP If Known
BIRTH DATE:
AGE:
EMERGENCY CONTACT:
EMERGENCY CONTACT PHONE NUMBER:
RELATIONSHIP:
MARITAL STATUS:
- Married
- Divorced
- Widowed
- Domestic Partnership
- Single

PRIMARY PHYSICIAN:
PRIMARY PHYSICIAN'S CLINIC:
PRIMARY PHYSICIAN'S ADDRESS:
DATE OF LAST VISIT:
LIST ANY MAJOR HOSPITALIZATIONS, OPERATIONS OR ILLNESS (INCLUDE WHEN THEY OCCURED & ANY DETAILS):
List current Rx Medicines & Used in the past 6 Months (Include Dose, How Often & Reason for Medication)
Any Medication Allergies:
- YES
- NO
IF YES, PLEASE LIST:
Tobacco Use:
- Yes
- No
How Much?
Drink Alcohol:
- Yes
- No
How Much?
GENDER*
Personal & Family History
Check all symptoms you have experienced in the last 6 months
- BLOATING, GAS, FLATULENCE
- HAIR LOSS - FALLING OUT
- SENSITIVE TO COLD
- HEARTBURN,REFLUX
- DRY HAIR
- PALPITATIONS/FLUTTERS
- CONSTIPATION
- THINNING HAIR
- DIFFICULTY GETTING TO SLEEP
- HEMORRHOIDS
- NAUSEA/VOMITING
- INSOMNIA
- BOWEL HABIT CHANGES
- EARS RINGING/DIZZINESS
- PSORIASIS/ACNE FLAREUPS
- COUGHING/WHEEZING
- FATIGUE
- DRY SKIN
- FOOD ALLERGIES/INTOLERANCES
- SEASONAL ALLERGY FEVER
- TIRED UPON WAKING
- FRONTAL HEADACHES/SINUSITIS
- URINARY TRACT INFECTIONS
- ARTHRITIS/JOINT ACHES & PAINS
- CRAVINGS - SWEETS
- COLD HANDS/FEET
- LOWER BACK PAIN STIFFNISS
- CRAVINGS -SALT
- POOR CIRCULATION
- DEPRESSION WEEPINESS
- CRAVINGS- BEER WIN LIQUOR
- PUFFY FACE SWOLLEN EYELIDS IN MORNING
- ANXIETY IRRITABILITY TEMPER
ABNORMAL BLOOD PRESSURE
- Child
- Siblings
- Father
- Mother
- Self
ARTHRITIS OR JOINT PROBLEMS
- Child
- Siblings
- Father
- Mother
- Self
ASTHMA BRONCHITIS
- Child
- Siblings
- Father
- Mother
- Self
AUTOIMMUNE DISEASE
- Child
- Siblings
- Father
- Mother
- Self
BLOOD DISORDERS/ANEMIA
- Child
- Siblings
- Father
- Mother
- Self
CANCER/TUMORS/CYSTS
- Child
- Siblings
- Father
- Mother
- Self
COLITIS
- Child
- Siblings
- Father
- Mother
- Self
CROHN'S DISEASE
- Child
- Siblings
- Father
- Mother
- Self
DEPRESSION/MENTAL ILLNESS
- Child
- Siblings
- Father
- Mother
- Self
DIABETES
- Child
- Siblings
- Father
- Mother
- Self
ECZEMA/PSORIASIS
- Child
- Siblings
- Father
- Mother
- Self
ENDOCRINE DISORDER
- Child
- Siblings
- Father
- Mother
- Self
EPILEPSY
- Child
- Siblings
- Father
- Mother
- Self
EXCESSIVE BLEEDING
- Child
- Siblings
- Father
- Mother
- Self
GALLSTONES
- Child
- Siblings
- Father
- Mother
- Self
HEART DISEASE
- Child
- Siblings
- Father
- Mother
- Self
HERPES/COLD SORES
- Child
- Siblings
- Father
- Mother
- Self
HIGH CHOLESTEROL/LIPIDS
- Child
- Siblings
- Father
- Mother
- Self
HIV
- Child
- Siblings
- Father
- Mother
- Self
HEPATITIS
- Child
- Siblings
- Father
- Mother
- Self
HPV/HUMAN PAPILLOMAVIRUS
- Child
- Siblings
- Father
- Mother
- Self
JAUNDICE/LIVER DISEASE
- Child
- Siblings
- Father
- Mother
- Self
KELOID SCARRING
- Child
- Siblings
- Father
- Mother
- Self
KIDNEY INFECTIONS/STONES
- Child
- Siblings
- Father
- Mother
- Self
EMPHYSEMA
- Child
- Siblings
- Father
- Mother
- Self
MELANOMA/SKIN CANCER
- Child
- Siblings
- Father
- Mother
- Self
PARASITES
- Child
- Siblings
- Father
- Mother
- Self
PHLEBITIS/VARICOSE VEINS
- Child
- Siblings
- Father
- Mother
- Self
PNEUMONIA
- Child
- Siblings
- Father
- Mother
- Self
REOCCURRING INFECTIONS
- Child
- Siblings
- Father
- Mother
- Self
RHEUMATIC FEVER
- Child
- Siblings
- Father
- Mother
- Self
RHEUMATOID ARTHRITIS
- Child
- Siblings
- Father
- Mother
- Self
THYROID DISEASE
- Child
- Siblings
- Father
- Mother
- Self
TUBERCULOSIS
- Child
- Siblings
- Father
- Mother
- Self
SEIZURES
- Child
- Siblings
- Father
- Mother
- Self
STROKE
- Child
- Siblings
- Father
- Mother
- Self
ULCERS
- Child
- Siblings
- Father
- Mother
- Self
MALE HORMONE QUESTIONNAIRE:
ADAM questionnaire about symptoms of low testosterone (Androgen Deficiency in the Aging Male) The basic questioner can be very useful for men to describe the kind and severity of their low testosterone one symptoms.
Do you regularly experience poor sleep?
- Yes
- No
Are you constantly tired and lacking of energy?
- Yes
- No
Do you regularly experience stomach or other gut related issues like bloating, gas, or irregular bowel movements?
- Yes
- No
Do you crave sugars?
- Yes
- No
Have you recently experienced weight gain?
- Yes
- No
Are you experiencing thinning or increased shedding of hair?
- Yes
- No
Have you lost height?
- Yes
- No
Do you have a decrease in libido (sex drive)?
- Yes
- No
Are your erections less strong?
- Yes
- No
Have you noticed a recent deterioration in your work performance?
- Yes
- No
Are you usually anxious and have a hard time relaxing?
- Yes
- No
Do you often feel cold when those around you don't?
- Yes
- No
Do you regularly experience "brain fog"?
- Yes
- No
Have you noticed a decreased “enjoyment of life” ?
- Yes
- No
Are you sad and/or grumpy?
- Yes
- No
Do you have a decrease in strength and/ or endurance?
- Yes
- No
Do you need to consume coffee/energy drinks/caffiene to function?
- Yes
- No
FEMALE HORMONE QUESTIONNAIRE:
Telltale Symptoms of Hormonal Imbalance in Women (HIMB) This basic questionnaire can be very useful for women to describe the kind and severity of their low estrogen symptoms.
Do You Currently Have A Monthly Cycle?
- Yes
- No
Irregular Periods
- Yes
- No
Sleep Issues
- Yes
- No
Yeast Infections
- Yes
- No
Crave Sweet/Sugar?
- Yes
- No
Stomach Issues
- Yes
- No
Extreme Fatigue
- Yes
- No
Depression/Irritability
- Yes
- No
Weight Gain
- Yes
- No
Headaches
- Yes
- No
Lowered Libido
- Yes
- No
Breast Changes
- Yes
- No
Night Sweats
- Yes
- No
SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLY
IRREGULAR CYCLES
LIGHT MENSTRUAL FLOW
SWOLLEN TENDER BREASTS
SWOLLEN BELLY
LOSS OF MUSCLE TONE
VAGINAL DRYNESS
IRRITABLE & AGGRESSIVE BEHAVIOR
INCREASED BELLY FAT
CRAMPS
HEAVY PERIODS
FATIGUED, FEELING EXHAUSTED
PAINFUL INTERCOURSE
PAINFUL PERIODS
REDUCED LIBIDO
HOT FLASHES
LOSS OF SELF CONTROL
MEMORY LAPSES/MENTAL FOG
HAIR LOSS ON TOP OF HEAD
RESTLESS, LIGHT SLEEP
WEIGHT GAIN
DEPRESSION
ANXIOUS
MEDICAL CONSENT AGREEMENT:
This agreement between ("Patient'') and Vital Force Therapy & Wellness. Vital Force and patient agree that these guidelines and conditions are an essential factor In maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore these agents are prescribed with caution. The patient agrees and accepts to the following conditions:
1. I understand that the Vitamins I am receiving for me based on diagnoses derived from my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions In accordance with applicable state and Federal law.
2. I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.
3. I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
4. I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effect related to my treatment to Vital Force Therapy & Wellness and discontinue use until advised to resume usage by my health care provider.
5. I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy.
6. I understand that representatives of Vital Force Therapy & Wellness and/or Licensed Physicians Assistant are available 'for questions and/or. concerning during normal business hours throughout the course of my treatment.
7. I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided by Vital Force Therapy & Wellness or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third party payer.
8. I agree that the Vital Force Therapy & Wellness/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Vital Force Therapy & Wellness will be in conjunction with the care provided by my current PCP.
9. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication In its respective labeled container.
10. I have read and agree to the terms of this the Therapy Management Agreement.
11. I consent to text message appointment reminders. (Data rates may apply)
Signature
Date
MM slash DD slash YYYY
Marketing Agreements
Here at Vital Force Therapy & Wellness, we like to stay in touch with our current and potential patients via e-mail, text messages, and social media. We would love to have you involved but understand the hesitation. Please read and mark the options below if you are uninterested in these marketing approaches.
- I would like to OPT OUT of promotional e-mails and text messages.
- I do NOT agree to having my photo posted on social media for promotional postings.

Vital Force Therapy & Wellness Intake Form

Patient Information

Personal & Family History

MALE HORMONE QUESTIONNAIRE:

FEMALE HORMONE QUESTIONNAIRE:

SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLY

MEDICAL CONSENT AGREEMENT:

Vital Force (formerly Revive IV Therapy) | Birmingham AL

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