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The Perfect Pregame Mobile IV - Health History Questionnaire

To ensure your safety and provide you with the best possible care during your IV infusion session with The Perfect Pregame Mobile IV, please take a moment to complete the following health history questionnaire. Your responses will remain confidential and will only be used by our healthcare professionals to tailor your treatment to your specific needs.

1. Personal Information:

Full Name

Contact Number

Date of Birth

Email Address

Emergency Contact Name

Emergency Contact Number

2. Medical History

Do you have any chronic medical conditions? If yes, please specify

Have you ever experienced any allergic reactions to medications or substances? If yes, please specify

Are you currently taking any medications? If yes, please list them

Do you have a history of fainting, dizziness, or low blood pressure?

Have you ever been diagnosed with any heart, kidney, liver, or lung conditions

Are you pregnant or breastfeeding?

3. Lifestyle and Habits

Do you smoke cigarettes, use e-cigarettes, or vape?

Do you consume alcohol? If yes, how much have you consumed today?

Do you use recreational drugs? If yes, have you used any today?

4. Additional Information

Is there anything else you believe we should know about your health history or any concerns you have regarding the IV infusion treatment?

Please provide as much detail as possible to help us ensure your safety and optimize your IV infusion experience. If you have any questions or require assistance completing this questionnaire, please don't hesitate to contact us.

Thank you for your cooperation.

Sincerely,

The Perfect Pregame Mobile IV Team

Welcome to The Perfect Pregame Mobile IV Orlando

The Perfect Pregame Mobile IV - Health History Questionnaire

1. Personal Information:

2. Medical History

3. Lifestyle and Habits

4. Additional Information

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Mobile IV