Iron Wellness Quiz Name(Required) First Email(Required) Section 1: SymptomsFatigue: On a scale from 1 to 5 (1 being none, 5 being severe), rate your level of fatigue. 1 2 3 4 5 Dizziness: Do you experience dizziness or lightheadedness on a regular basis? Yes No Exercise Intolerance: Do you find it challenging to engage in physical activities due to fatigue or elevated heart rate? Yes No Low Mood: Do you experience a persistently low mood or feelings of sadness? Yes No Anxiety: Do you frequently feel anxious or nervous? Yes No Sleep Disturbances: Are you facing difficulties with sleep patterns? Yes No Thinning Hair or Hair loss of more than an average of 20 hairs a day Yes No Section 2: Recent Blood WorkWhen was your most recent blood work MM slash DD slash YYYY Have your labs shown a ferritin level below 60? Yes No if Yes, please provide the value: (#)Were the following labs run: CBCSelect oneYesNoWere the following labs run: FerritinSelect oneYesNoWere the following labs run: Iron PanelSelect oneYesNoWere the following labs run: B12 and FolateSelect oneYesNoSection 3: Oral Iron SupplementsAre you currently taking oral iron supplements? Yes No If yes, how many mg of iron are you taking?If yes, how well are they tolerated? Well Tolerated Not Well Tolerated If yes, do you experience constipation? Yes No IV Treatment: Have you ever received an IV treatment before? Yes No Section 4: IV Treatment ExperienceDo you find that symptoms continue, or iron levels remain low despite oral supplementation? Yes No Call to schedule a consolation today or ask your provider at your next visit if an iron IV is right for you!