Health Questionnaire

If you’re new to The IV Lounge, or you haven’t seen us in 2 or more years, you’ll need to fill out this health questionnaire before you can make a booking.

"*" indicates required fields

Step 1 of 5

Full name*

Email address*

Phone number*

Date of birth*

Gender*

NHI Number (if known)

Emergency contact name*

Emergency contact phone*

Reason for seeking infusion, e.g. fatigue, general wellness, infection, pain, stress(mental/physical), illness, burnout (please be as specific as possible)*

What infusion are you considering?*

Do you have any allergies to medications, supplements, vitamin preparations, foods, or tapes (including sulphur allergies)*

Do you have upcoming/ have you recently had, any MRIs, CT, PET scans or surgeries? (if yes, please explain)*

Are you currently on chemotherapy or receiving radiation?*

Have you ever had dialysis, have a AV fistula or had lymph glands removed from your armpit/chest wall (if yes, which side)?*

Are you a current smoker?*

Please list all medications you are currently taking, including dose and frequency (e.g, Digoxin, Chloramphenicol, Arsenic Trioxide)*

Do you have known known physical or mental health conditions? (e.g, G6PD deficiency, clotting disorders, cancer, mental disorders, kidney disease, urinary stones, diabetes, etc.)*

Are there any medical conditions that run in your family? (e.g, G6PD deficiency, clotting disorders, cancer, mental disorders, kidney disease, urinary stones, diabetes, etc)*

Some patients who are prescribed ongoing IV infusions need blood tests. Do you consent to a Registered Nurse taking a blood sample, as directed by our Medical Practitioner?*

Would you like IV Lounge to forward blood test results to your GP? If yes please provide your GPs name and clinic*

Do you have a personal medical history of any of the following?*

Do you take medications, supplements or had surgery for any of these these? Which ones?*

Do you have any issues with needle cannulation?*

If so please advise us of the details*

Are you pregnant? If so, who is your LMC?*

Are you breastfeeding?*

What is your weight (kg)?*

What is your height (cm)?*

I declare that all health information provided on this form is true and accurate. I consent for a general practitioner to access my online medical records using the given information. I agree to update the IV lounge Registered Nurse if I am diagnosed with any new medical conditions, or begin any new medications.*

Patient name*

Patient sign*

Today's date*

Prescription Fee

A non-refundable $50 prescription fee is required to complete this health questionnaire. By submitting this form, you authorise a charge of NZ$50 to the credit card information provided below.

Non refundable prescription fee

Price:

Credit Card