Iron Infusion Assessment Form Surname(Required) First name(s)(Required) Preferred name Gender Male Female Gender neutral Other TitleMrMrsMissMasterMsDrProfDate of Birth(Required)Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home address Street Address City ZIP / Postal Code Postal address (if different): Contact DetailsHomeWorkMobile(Required)Email address(Required) Next of kin name Emergency contact details G.P. name Medical centre Occupation Previous illness/surgeries(Required)Pregnancy/Breastfeeding(Required)Allergies(Required)Current medications(Required)What are your main reasons for considering an iron infusion (provide as much detail as possible).(Required)Have you had an iron infusion or iron injections before?(Required) Yes No If yes whenDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you tried oral iron supplementation?(Required) Yes No If Yes provide detailsDid you experience any side effects from oral iron supplementation?(Required) Yes No If Yes provide detailsHave you had anaemia investigated?(Required) Yes No If Yes provide detailsDo you have hypothyroidism?(Required) Yes No If Yes what treatment do you takeHave you had any of the following?Weight loss surgery(Required) Yes No Intestinal bleeding(Required) Yes No Diet lacking iron(Required) Yes No Vegan/Vegetarian(Required) Yes No Absorption issues(Required) Yes No Anti acid medications(Required) Yes No Coeliac disease(Required) Yes No Current weight (kg) Have you had recent blood tests?(Required) Yes No If Yes if possible please email a copy to ivboutiquenz@gmail.comFemales only:Heavy menstrual blood loss(Required) Yes No N/A Multiple pregnancies(Required) Yes No N/A Birthing hemorrhage(Required) Yes No N/A CommentsThis field is for validation purposes and should be left unchanged.
