Name: Recovery Hydration Therapy
Address: Kansas City, MO, U.S.

CLIENT INFORMATION & MEDICAL HISTORY

In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential.

Today's Date*
Client Name*
First Last
Date of Birth*
Age*
Occupation*
Home Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
How were you referred to us?*
MEDICAL HISTORY
Are you currently under the care of a physician?*
- Yes
- No
If Yes, for what?
Do you have any of the following medical conditions?
- Diabetes
- Infection
- High Blood Pressure
- Seizure Disorder
- Thyroid Disease
- Cardiac Disease
- Lung Disease
- Gastrointestinal Disease
Please check all that apply
Do you have any other health problems or medical conditions?
Please List
Allergies: Have you ever had an allergic reaction?*
- Food Allergy
- Medication Allergy
- Other Allergy
- No know allergies
Check all that apply.
List any and all allergies that you have checked above and describe the reaction you experienced.
Medications*
What oral prescription medications are you presently taking? (It is required you list all of them) If you are not taking any medications type 'None'.
What herbal supplements do you take regularly?*
(It is required you list all of them) If you are not taking any supplements type 'None'.
For Our Female Patients
Are you pregnant or trying to become pregnant?
- Yes
- No
Are you breastfeeding?
- Yes
- No
Electronic Signature*
- I agree
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professional of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. The treatments I receive here are voluntary. I understand there is a risk, including but not limited to, allergic reaction, skin irritation, nausea, vomiting, gastrointestinal upset, and flushing. I release Recovery Hydration Therapy, INC and my provider from liability and assume full responsibility.
Name
This field is for validation purposes and should be left unchanged.

Kansas City’s Recovery Hydration Therapy: Service Forms

CLIENT INFORMATION & MEDICAL HISTORY

MEDICAL HISTORY

For Our Female Patients

DOWNLOAD HIPPA DOCUMENT

DOWNLOAD CLIENT INFORMATION & MEDICAL HISTORY DOCUMENT

Schedule your Treatment Today!