Wyoming Wellness Center

Nutritional IM / IV Infusion-Medical Intake Form

Please fill out this form completely. Please be as detailed as possible. We do not want to delay your care due to missing information or need for clarification. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

First Name * Last Name * Date of Birth * Sex * Cell Phone * Email Address *

Additional Information

Emergency Contact Name * Emergency Contact Number * Who is your Primary Care Provider (PCP)? * What is the Telephone number of your PCP? *

Medical History

What is your Height? * What is your Weight? * List ALL medications you are currently taking (INCLUDING OVER THE COUNTER, VITAMINS, & SUPPLEMENTS)) * List ALL Medication Allergies * List ALL Environmental/Food Allergies * Please check all Medical conditions that apply * Type of Cancer **If Applicable** Special Medical Conditions: Check ALL that apply to you * Describe ANY OTHER Medical Conditions OR ANY Conditions Marked above IF more detail is needed * Female and Obstetrical HISTORY *

Surgical History

Please check all Surgical Procedures you have had: *

Social History

Do you use Caffine? *Check all that Apply * Do you Smoke or Vape? * Do you use chewing tobacco? * Do you drink alcohol? *Check all that Apply * Do you use the following drugs? *Check all that Apply * If "Other" Selected, Please List name of Drug and what Dose or Strength you take: If you selected any drugs listed above, How often are you taking them? * Main Physical and Emotional Complaints **(Please check all that apply)** * Which Statements Best Describe Why You Want Nutritional or Hydration Therapy? **(Check all that apply)** * What Type of Nutritional or Hydration Therapy are you requesting or interested in? * How Did You Hear About Us? *