Iron Wellness Quiz - Amber Wellness Group

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Iron Wellness Quiz

Name(Required)

First

Email(Required)

Section 1: Symptoms

Fatigue: 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 Work

When 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: CBC

Were the following labs run: Ferritin

Were the following labs run: Iron Panel

Were the following labs run: B12 and Folate

Section 3: Oral Iron Supplements

Are 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 Experience

Do 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!

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