Do you take any of the following medications? *

laxatives

diuretics

anti-inflamatories

anti-hypertensives

none of the above

Do you take any nutritional supplements? *

Yes

No

Do you suffer from any of these diseases *

diabetes

urinary tract infection

bowel disease

heart failure

kidney disease

other

If other disease, please specify:

Are you pregnant? *

Yes

No

Do you suffer from any of these symptoms? *

shivers

constipation

diarrhea

dizziness

cramps

tachycardia

headache

asthenia/fatigue

dry mouth

lack of concentration

none of the above

Do you usually have a bottle of water with you when you’re outside? *

Yes

No

Do you take a bottle of water with you when you go to work? *

Yes

No

Do you drink bottled water at home? *

Yes

No

Do you frequently consume bottled water? *

Yes

No

Do you drink any water while performing physical activity? *

Yes

No

If so, please indicate the quantity of water you consume:

Do you consume isotonic and/or energy drinks while performing physical activity? *

Yes

No

If so, please indicate the quantity of isotonic/energy drinks you consume:

Do you consume any fluid before you feel thirsty? *

Yes

No

Do you drink water for pleasure? *

Yes

No

When you’re thirsty, do you prefer to consume beverages other than water? *

Yes

No

If so, please indicate which beverages:

Do you feel full after drinking liquids? *

Yes

No

Do you know what the recommended daily amount of water is for a healthy adult? *

Yes

No

If so, please indicate the amount:

Congratulations on starting your IV hydration treatment at Prestige 2.0.

Someone from Prestige 2.0 will reach out to you shortly to complete the medical evaluation. In the meantime, please provide the following information and then schedule your appointment.

First Name

Last Name

Phone *

Email *

Date of birth

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