02 Interval Health Check SINCE LAST VISIT
01 Any change in health, new diagnosis, ER visit, or hospitalization?
02 Any new or changed medications or supplements?
03 Current illness, fever, infection, nausea, vomiting, or diarrhea?
04 Any new allergies or sensitivities?
05 Any reaction to a prior infusion (rash, lightheadedness, etc.)?
06 Known kidney, liver, or heart condition / fluid restriction?
07 Pregnant, possibly pregnant, or breastfeeding?
08 Adequate food & fluids in the last several hours?
04 Patient Signature
Sign inside the box with your finger, stylus, or mouse. My answers above are accurate, and I consent to today's infusion under my consent on file.
05 Clinical Clearance STAFF USE
