IV Therapy Screening and Consent Name Form Instructions: DO NOT USE THE BACK BUTTON DO NOT REFRESH YOUR BROWSER Once submitted this form cannot be revised or edited. Use the Addendum form if necessary. Event Location State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Infusion Date Infusion Start Time Infusion End Time Participant Information Participant's First Name Participant's Last Name Participant's Email Participant's Phone number Participant's Address Date of Birth Last 4 of SS# Participant's Age Participant's Weight Sex MaleFemale Screening Questions Alert & Oriented A&O X 4 Person Place Time Event Allergies NKDA Allergies Patient Medications Last Oral Intake Reason for Infusion, sick, hangover, re-hydrate, etc. Past Medical History AMI CHF Diabetes CVA HTN Seizures COPD Asthma Cardiac OTHER: PMH OTHER Breathing NORMAL Shallow Retractions Labored Absent Rapid Lungs Sounds CLEAR Wheezes Rales Rhonchi Diminished Absent Mark all that apply Does getting an IV make you nervous? Have you recently had, or currently have a cold or the flu? Do you have a heart condition? Have you ever been diagnosed with high blood pressure (hypertension) or heart failure? Do you have asthma, bronchitis, or any other breathing problem? Are you experiencing chest pain? Have you had hepatitis, liver disease, or jaundice? Do you have, or have you ever had, kidney disease? Do you have numbness, weakness, or paralysis of your extremities Have you ever been diagnosed with Myeloma, Lupus, Scleroderma, Gout, Sickle-cell disease, Hyperthyroidism, or Myasthenia Gravis? Do you have bleeding problems or clotting issues? (Men) In the last 48 hours, have you taken, Viagra, Cialis, or other erectile dysfunction medicines? A "Yes" answer to any of these questions suggests the patient should not receive elective IV therapy. Additional explanation is required. Please explain any YES answers below. It is suggested not to providing the service unless suitable clarification and/or medical director counsel is sought. If providing services with a YES answer, please provide your reasoning for proceeding Explain any Yes answers Vitals Pre-Infusion vitals Time BP Pulse Respiration Vitals during Infusion Time BP Pulse Respiration Post Infusion vitals Time BP Pulse Respiration Treatment Provided IV Bag 1000cc NS 500cc NS 1000cc LR 500cc LR Additives No Additives B-12 IV Guage 18 20 22 Drip Set 10gtts Drip Rate (10gtts set) TKO 1L/60 min | 167 gtt/min (42 gtt/15sec) 1L/45 min | 222 gtt/min (56 gtt/15sec) 1L/30 min | 333 gtt/min (83 gtt/15sec) Other Treatments Did you give any OTC's? YesNo Over the Counter Medications Ibuprofen Benadryl Tylenol Clairton Dayquil Sudafed Dramamine Antacid tablets Anti-Diarrheal Emergen-C Midol Cough Drops B-12 tablets Insta-Glucose Electrolyte tabs Baby Aspirin 81mg OTC notes Did you use Oxygen? YesNo Oxygen NC NRB BVM Suction L/min 2 LPM 4 LPM 6 LPM 10 LPM 15 LPM Oxygen Notes Procedure Notes/Narrative Medical Professional Medic's Name and Title * Consent: By clicking this box I affirm that I have performed a detailed medical screening, answered all the participant questions and explained the risks and benefits to the participant to the best of my ability. See Privacy Policy * Report Date *
