"Intramuscular Injection Intake Form - Vitae Health Center"

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B12 INTRAMUSCULAR INJECTION INTAKE FORM
Patient Information:
Name: ________________________________________ Date: __________________
Address: _____________________________________________________________
City: __________________ State: ____________ ZIP Code: _______________
Phone: _________________(H) __________________(C) _________________(other)
Date of Birth: _________________________(D/M/Y) Age: ______ Sex: M / F
(circle one)
Occupation: _______________________ Email address: _______________________
Would you like to receive our quarterly newsletter via email? Yes______
No______
In case of emergency, who should we contact: ________________________________
What are your main complaints?___________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Please check if you have any of the following:
□ Fatigue
□ Low depressed mood
□ Pernicious Anemia
□ Weight issues
□ Irritability/moodiness
□ Pregnant /trying to be pregnant
□ Heart Disease
□ Diabetes
□ Memory Loss/Alzheimer’s
□ Sleep disorders
□ Osteoporosis
□ Tendonitis
□ Asthma
□ Allergies
□ Immunosuppression
□ Thyroid disorders □ IBS/Inflammatory Bowels □ Numbness or tingling of body
How did you learn about this service?
□ Already a Client
□ Advertisement
□ Website
□ Living Social
□ Web Search
□ Referred by: ___________________________________________________
□ Walk-In/Sign
□ Other: ________________________________________________________
If you purchased a package: An injection will be deducted from your package for every
missed appointment or late cancellation (less than 24 hours notice).
Informed Consent for Treatment I have read the information regarding risks and benefits of B12 on page 2
and have had a chance to ask questions on the treatment. I understand the possible complications of
injection therapy are minor bruising and bleeding at injected sites, dizziness, headaches and possible
fainting from the site of blood. I understand clearly that there may be a slight chance for sensitivities and
reactions to the B12 solution. I hereby release Dr. Brenden Cochran and Dr. Susan H. Mueller from all
liabilities regarding my treatment with B12 injections.
___________________________________________________________________
Patient Signature
Date (dd/mm/yy)
B12 INTRAMUSCULAR INJECTION INTAKE FORM
Patient Information:
Name: ________________________________________ Date: __________________
Address: _____________________________________________________________
City: __________________ State: ____________ ZIP Code: _______________
Phone: _________________(H) __________________(C) _________________(other)
Date of Birth: _________________________(D/M/Y) Age: ______ Sex: M / F
(circle one)
Occupation: _______________________ Email address: _______________________
Would you like to receive our quarterly newsletter via email? Yes______
No______
In case of emergency, who should we contact: ________________________________
What are your main complaints?___________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Please check if you have any of the following:
□ Fatigue
□ Low depressed mood
□ Pernicious Anemia
□ Weight issues
□ Irritability/moodiness
□ Pregnant /trying to be pregnant
□ Heart Disease
□ Diabetes
□ Memory Loss/Alzheimer’s
□ Sleep disorders
□ Osteoporosis
□ Tendonitis
□ Asthma
□ Allergies
□ Immunosuppression
□ Thyroid disorders □ IBS/Inflammatory Bowels □ Numbness or tingling of body
How did you learn about this service?
□ Already a Client
□ Advertisement
□ Website
□ Living Social
□ Web Search
□ Referred by: ___________________________________________________
□ Walk-In/Sign
□ Other: ________________________________________________________
If you purchased a package: An injection will be deducted from your package for every
missed appointment or late cancellation (less than 24 hours notice).
Informed Consent for Treatment I have read the information regarding risks and benefits of B12 on page 2
and have had a chance to ask questions on the treatment. I understand the possible complications of
injection therapy are minor bruising and bleeding at injected sites, dizziness, headaches and possible
fainting from the site of blood. I understand clearly that there may be a slight chance for sensitivities and
reactions to the B12 solution. I hereby release Dr. Brenden Cochran and Dr. Susan H. Mueller from all
liabilities regarding my treatment with B12 injections.
___________________________________________________________________
Patient Signature
Date (dd/mm/yy)
B12 Facts:
□ B12 injections are typically used as a treatment for a certain type of anemia (pernicious anemia). In
this type of anemia, people lack intrinsic factor in the stomach which is necessary for the absorption
of the vitamin.
□ Vegetarians (especially vegans) are also given shots of B12 since their diet is low in animal
products, the primary source of B12.
□ People with chronic fatigue or anemia require weekly to monthly injections of vitamin B12
usually because the oral form is not dependable.
□ Vitamin B12 shots are most effective when taken at regular intervals (usually weekly or monthly).
A regular schedule to receive the injections can be customized to each individual.
□ The body's ability to absorb vitamin B12 is reduced with increasing age. Older people are often
detected to have a more potent vitamin B12 deficiency, even in cases where they do not suffer
from pernicious anaemia.
□ Methylcobalamin (Methyl B12) is a unique form of vitamin B12, which is more readily converted
into the coenzyme forms than conventional cyanocobalamin. Mehtylcobalamin also readily binds
body stores of cyanide,
□ Deficiency of vitamin B12 can lead to abnormal neurologic and psychiatric symptoms including
ataxia (shaky movements and unsteady gait), muscle weakness, spasticity, incontinence,
hypotension, vision problems, dementia, psychoses, and mood disturbances
Initial here _________
Benefits of B12
□ More energy, mental alertness and stamina for everyday tasks
□ Healthier immune systems
□ Improves sleep
□ Increases metabolism, thereby aiding in weight loss
□ Reduces allergies, stress and depression
□ Improves mood stabilization
□ Lessens frequency and severity of migraines and headaches
□ Helps lower homocysteine levels in the blood, thereby reducing the probability of heart
diseases and strokes
Initial here _________
Possible Side Effects and Contraindications of B12
□ A vitamin B12 shot is safe and generally has no side effects, even in higher doses.
□ Some redness and swelling at the injection site may occur. This should start to get better within forty-
eight (48) hours.
□ In rare cases, B12 can cause diarrhea, peripheral vascular thrombosis, itching, transitory exanthema,
urticaria, feelings of swelling of the whole body.
□ Sensitivity to cobalt and/or cobalamin is a contraindication.
□ People with chronic liver and/or kidney dysfunction should not take frequent B12 injections; therefore
we ask that you please provide us with a recent copy of lab work, which reflects liver and kidney
function. This lab work is usually referred to as a metabolic panel. If you have not checked your lab
work recently, we ask that you get a complete blood workup as soon as possible.
□ Interactions with drugs: Chloramphenicol can impede on the red blood cell producing properties of
B12
□ Other drugs that decrease or reduce absorption of B12: antibiotics, cobalt irradiation, colchicine,
colestipol, H2-blockers, metformin, nicotine, birth control pills, potassium chloride, proton pump
inhibitors such as Prevacid, Losec, Aciphex, Pantaloc, and Zidovudine.
□ B12 is contraindicated in Leber’s disease, a hereditary optic nerve atrophic condition
Initial here _________
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