Hydration Therapy Service Forms Serving Kansas City 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* Date Format: MM slash DD slash YYYY Client Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Email* Emergency Contact Name* First Last Emergency Contact Phone*How were you referred to us?*MEDICAL HISTORYWhat symptoms are you currently experiencing?What treatment are you interested in receiving?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 applyDo you have any other health problems or medical conditions?Please ListAllergies: 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 PatientsAre 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.NameThis field is for validation purposes and should be left unchanged. DOWNLOAD HIPPA DOCUMENT DOWNLOAD CLIENT INFORMATION & MEDICAL HISTORY DOCUMENT Schedule your Treatment Today! Book Now
