IV Therapy Medical History & Screening Form

Because IV therapy delivers vitamins straight into the bloodstream, screening isn’t a formality — it’s the safety backbone of the whole treatment. This form gathers a careful medical history: heart, kidney and liver conditions, pregnancy, diabetes, G6PD deficiency which matters for high-dose vitamin C, blood and clotting disorders, regular medications, allergies and recent illness. It’s written to support a prescriber’s review, which is how responsible IV clinics operate. A dedicated free-text field captures all medications and allergies in detail, a question confirms the client has eaten and hydrated — which affects how they tolerate a drip — and a consent line records that they understand a qualified prescriber assesses their suitability and may decline treatment on medical grounds. That makes the screening both thorough and clearly professional. Have every client complete it before treatment and refresh it over time. It’s free, brand-styled, and turns the most important safety step in IV therapy into a clear, dated record.