IV Therapy Questionnaire| Henry County and Clayton County, GA

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360 Med Spa

(678)-283-6923

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Lifestyle Questionnaire

Pre-Assessment Form

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We are excited at the chance to help you feel better. Please take the time to complete the below form and submit it prior to your appointment. This information is important for us to help you achieve your health goals.

Today's Date:

Name:

Phone:

Email:

Date of Birth:

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To help us see where we can help your life better, please check all that apply:

Field label

WOMEN:

New Field:

Low Energy

Low Sex Drive

Fatigued Burned Out Feeling

Weight gain

Thinning hair

Hot flashes

Night sweats

Headaches

Depression / Anxiety

Foggy brain / Memory loss

Irritable

Breast tenderness

Water retention

Vaginal dryness

Difficulty with orgasm

Heavy or irregular cycle

Cramps

Fibrocystic breasts

Menopause / Post-MP bleeding

History of thyroid issues

Chronic pain

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MEN

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Low energy

Low sex drive

Fatigue / Burned out feeling

Weight Gain

Thinning hair

Headaches

Decreased urine flow

Increased urinary urge

Exercise intolerance

Difficulty sleeping

Depression / anxiety

Irritable

Chest/nipple sensitivity

Erectile performance

Night sweats

Poor concentration

Muscle cramps

Chronic pain

SKIN (both men and women)

Wrinkles / Fine Lines

Loose or sagging skin

Sagging cheeks

Acne, Rosacea

Sunspots, hyperpigmentation

Gastrointestinal (both Women and Men)

Bloating after meals

Sugar cravings

Constipation

Upset stomach

History of ulcer

Any current prescriptions, allergies?

Any major surgeries or hospitalizations?

What treatments are you doing or have done to make you look and feel better?

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1~ IV Treatment

Lifestyle Assessments

Up to 37% Discount

Priority Booking

15% off Additional Infusions

2~ IV Treatments

Lifestyle Assessments

Up to 37% Discount

Priority Booking

15% off Additional Infusions

4~IV Treatments

Lifestyle Assessments

Up to 42% Discount

Priority Booking

15% off Additional Infusions

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