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HOME CARE IN CANNES & SAINT-TROPEZ THIS SUMMER
Infinite Drip
Thérapies IV
Plus
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Localisations
Paris
Genève
Cannes
Réserver
Connexion
PRE-INFUSION FORM
First Name
Last Name
Date of Birth
Gender
Nationality
Phone
Phone number of the support person
E-mail
Weight (kg)
Height (cm)
Do you have any allergies or allergic reactions?
*
Required
No
Yes
Have you recently consumed excessive amounts of alcohol?
*
Required
No
Yes
Do you have (or have you had) any heart or vascular problems?
*
Required
No
Yes
If yes, please give details :
High blood pressure
Thoracic pain
Heart attack, angina pectoris
Bypass surgery or coronary stent(s)
Valve damage
Shortness of breath on exertion
Cardiac insufficiency, acute pulmonary oedema
Tachycardia or rhythm disorder
Fainting, syncope
Pace Maker, Defibrillator
Arteritis
Bypass surgery(s) or stent(s) of the arteries of the lower limbs
Varicose veins
Phlebitis(es)
Pulmonary embolism(s)
Leg swelling
Do you (already) have any respiratory problems?
*
Required
No
Yes
If yes, please give details :
Asthma
Sleep apnea
Bronchitis
Emphysema
I'm smoking
Number of cigarettes/day
Other :
Since/years
Do you (ever) have neurological or psychiatric problems?
*
Required
No
Yes
If yes, please give details :
Cerebrovascular accident
Epilepsy
Meningitis
Migraines
Depression
Peripheral nerve damage
Brain surgery
Autres:
Do you have any bone, joint or spinal problems?
*
Required
No
Yes
If yes, please give details :
Arthrose
Sciatica
Scoliosis
Do you (ever) have urinary problems?
*
Required
No
Yes
If yes, please give details :
Kidney stones
Renal insufficiency
Infection(s)
Problems urinating (prostate)
Do you (ever) have abdominal or digestive problems?
*
Required
No
Yes
If yes, please give details :
Hepatitis
Gallstones
Cirrhosis
Pancreatitis
Blood in stools
Blood vomiting
Ulcer
Gastritis
Gastric reflux
Abdominal pain
Do you have (or have you had) any coagulation problems? Have you ever had a transfusion?
*
Required
No
Yes
If yes, please give details
Prolonged and/or unusual bleeding requiring consultation or treatment
Large hematomas (> 2 cm) without shock or very large for a minor shock
Are you taking anticoagulants?
Long and/or excessive menstrual periods
Prolonged or heavy bleeding after tooth extraction, surgery or childbirth
Known coagulation disease
Are you diabetic or do you have endocrine problems?
*
Required
No
Yes
If yes, please give details :
Diabetes
Thyroid disease
Adrenal gland disease
Are you often thirsty?
Are you often hungry?
Do you urinate frequently?
Are you or have you ever been treated for cancer?
*
Required
No
Yes
If yes
Chemotherapy
Radiotherapy
Do you have (or ever had) any ophthalmological problems?
*
Required
No
Yes
If yes, please give details :
Glaucoma
Radiotherapy
Other :
Have you ever had an allergic reaction or adverse reaction to any vitamin?
*
Required
No
Yes
Have you ever had an allergic reaction or adverse reaction to anesthesia?
*
Required
No
Yes
Are you pregnant or could you be pregnant?
*
Required
No
Yes
Are you currently breast-feeding?
*
Required
No
Yes
Are you currently taking medication? Have you taken any drugs within 24 hours?
*
Required
No
Yes
Which ones
Are you aware of any contraindications to receiving an IV infusion for any reason whatsoever?
*
Required
No
Yes
I hereby certify that the information given on this declaration is correct.
Done in (location)
On (date)
Please sign
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