Letz Drip

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Medical History & Health Information Form

This form helps us understand your health status to ensure safe and effective treatment. Please answer all questions honestly. All information will be kept confidential.

Disclaimer: In certain cases, your practitioner may require written consent from your General Practitioner (GP) before proceeding with treatment. This is to ensure your safety and that all procedures are conducted in line with clinical best practice.

Name
Gender
Address
Address

Medical Background

Please select if you have ever been diagnosed with or currently have any of the following conditions:
Heart disease / chest pain / angina
High cholesterol
Stroke / mini - stroke (TIA)
Kidney or liver disease
Diabetes (Type 1 / Type 2)
Asthma / COPD / breathing problems
Thyroid disorder (overactive/underactive)
Neurological conditions (e.g. MS, Parkinson’s)
Epilepsy / seizures
Blood disorders (anaemia, clotting, DVT, PE)
Autoimmune disorders (e.g. lupus, rheumatoid arthritis)
Cancer (past or present)
Bleeding or bruising tendencies
Recent surgery or hospital admission
Chemotherapy / radiotherapy history
Urinary tract or kidney problems
Gastrointestinal disorders (ulcers, IBS, Crohn’s, etc.)
Chronic pain / fibromyalgia
Joint or musculoskeletal disorders
Allergies (food, latex, medication, adhesives)
Skin conditions (eczema, psoriasis, dermatitis)
Migraines or frequent headaches
Migraines or frequent headaches
Eating disorders / nutritional deficiencies
Mental health conditions (depression, anxiety, PTSD, etc.)
Infectious diseases (Hepatitis, HIV, TB, etc.)
Immunosuppression or low immunity
Vaccinated
HIV infection
Vaccinated
Hepatitis B
Vaccinated
Hepatitis C
Recent infection, fever, or illness (past 4 weeks)
Blood-borne infections
Recent vaccination (within 2 weeks)
Current cold, flu, or COVID-19 symptoms
Currently under medical care or awaiting diagnosis
Fainting or dizziness (vasovagal syncope)
Varicose veins
Lymphatic issues (swelling, tightness, or pain)
Injury to skin or deep scar tissue
Phlebitis (vein inflammation)
Collapsed veins
Nerve damage
On Warfarin
Blood-thinning medication (e.g. warfarin, aspirin)

2. Allergies

3. Current Medications

4. Lifestyle Factors

Do you smoke?
Do you drink alcohol?
Do you use recreational drugs?
Do you follow a specific diet (e.g. vegan, keto, low salt)?

5. For Female Clients Only

Are you pregnant or breastfeeding?
Any issues with menstruation or menopause?
Are you currently using hormonal contraception or HRT?

6. For Male Clients Only

Do you have Prostate problems?
Do you have Erectile dysfunction?
Are you taking hormone replacement i.e. testosterone?

7. Previous IV Therapy / Reactions

Have you received IV therapy before?
Any reactions to previous infusions or injections?
Have you ever fainted or felt unwell during a medical procedure?

8. Consent & Declaration

I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that withholding medical information may increase the risk of adverse reactions during or after treatment. I agree to inform my practitioner of any changes to my health, medications, or allergies before any future treatments.

Clear Signature
Clear Signature

Confidentiality Notice:

All personal and medical information is treated as confidential in accordance with GDPR and CQC Information Governance Standards. This form will be securely stored in your client file and used only for treatment and safety purposes.