Medical Questionnaire – Revive and Refine Wellness Studio

PERSONAL INFORMATION

Full Name

Date of Birth

Age

Gender

Phone Number

Email Address

Emergency Contact Name

Phone

MEDICAL HISTORY

If Other, Please Enter Below

MEDICATIONS & ALLERGIES

Are you currently taking any medications, vitamins, or supplements?

If Yes, Please Add Them Below (Separate With Comma)

Do you have any allergies to medications, food, or IV therapy ingredients?

If Yes, Please Add Them Below (Separate With Comma)

IV HYDRATION & B12 INJECTIONS SCREENING

Are you currently pregnant or breastfeeding?

No Yes

Have you had recent lab work within the past 6 months?

If Yes, Please Select Date Below

Do you have a history of kidney disease, congestive heart failure, or fluid retention issues?

No Yes

Do you have a history of anemia, low B12, or neurological symptoms like tingling/numbness?

No Yes

MEDICAL WEIGHT LOSS SCREENING

Have you been diagnosed with or experienced any of the following?

Thyroid Issues (Hyperthyroidism/Hypothyroidism) Unexplained Weight Loss or Gain Eating Disorders (Anorexia, Bulimia, Binge Eating) Previous Use of Weight Loss Medications (Phentermine, Semaglutide, etc.)

Are you currently taking or have you taken any of the following in the last 3 months?

Phentermine, Contrave, or Qsymia Semaglutide (Wegovy, Ozempic), Tirzepatide (Mounjaro, Zepbound) Insulin or Diabetes Medications Steroids or Hormonal Therapy

Do you have a history of gallbladder disease, pancreatitis, or gastrointestinal disorders?

No Yes

LIFESTYLE & HABITS

How many days per week do you exercise?

None 1-2 Days 3-4 Days 5+ Days

Do you consume alcohol?

If Yes, How Often?

Do you smoke or use tobacco/nicotine products?

If Yes, How Often?

How many hours of sleep do you typically get per night?

Less than 5 5-6 7-8 9+

CONSENT & SIGNATURE

I certify that the information provided above is accurate to the best of my knowledge. I understand that misrepresentation of my medical history may increase the risk of complications. I consent to treatment at Revive and Refine Wellness Studio and understand that I may be required to provide additional medical documentation if necessary.

Client Signature

Date