Patient History Form

Are you currently taking any medications, supplements, or herbal remedies? If yes, please list them.

Have you experienced any adverse reactions or side effects to medications or treatments in the past? If yes, please describe.

Have you undergone any recent surgeries or medical procedures? If yes, please provide details.

Have you consulted with a healthcare professional regarding your decision to pursue IV InfuZEN therapy or weight loss services?

Yes No

Do you have a family history of:

Heart Disease Diabetes Cancer