Personal Information
Emergency Contact
Medical History
Do you have any allergies?
Current medications or supplements (please list names, dosages, and
reasons):
Chronic or recent medical conditions (please provide details):
Previous surgeries or hospitalisations (dates and reasons):
Have you had IV therapy before?
Are you pregnant or breastfeeding?
Do you have any of the following? (Tick and provide details if Yes):
Heart conditions
Kidney disease
Liver disease
Bleeding disorders
Immune system disorders
Any recent infections or illnesses?
Family medical history (relevant conditions):
Lifestyle Information
Do you smoke?
Do you drink alcohol?
Do you use recreational drugs?
How often do you exercise?
Dietary preferences or restrictions:
Consultation Details
Reason for IV drip therapy:
Preferred type of drip (if known):
What are your goals or expectations from this therapy?
Any additional concerns, symptoms, or requests:
Consent
Signature
Date
