Iron Infusion Assessment Form

Please complete the following form accurately. Your information will help our healthcare team provide you with the safest and most effective treatment plan.

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Do you often feel unusually tired or weak?

Yes

No

Have you noticed any pale or ashen color in your skin or the inside of your lower eyelids?

Yes

no

Do you experience shortness of breath or feel winded even after light physical activity?

Yes

No

Have you had episodes of dizziness, lightheadedness, or fainting?

Yes

No

Do you experience rapid or irregular heartbeats?

Yes

No

Are your hands or feet frequently cold or feel numb?

Yes

No

Do you have frequent or unexplained headaches?

Yes

No

Do you experience discomfort or the urge to move your legs when resting, especially in the evening or at night?

Yes

No

Do you follow a vegetarian or vegan diet?

Yes

No

Do you consume iron-rich foods (e.g., red meat, poultry, fish, lentils, spinach) regularly?

Yes

No

If yes, how often

Do you consume vitamin C-rich foods (e.g., citrus fruits, tomatoes, peppers) with meals that contain iron?

Do you regularly consume foods or beverages that can inhibit iron absorption (e.g., coffee, tea, dairy, whole grains)?

Do you have heavy or prolonged menstrual periods?

Have you had any recent surgeries, blood donations, or other causes of significant blood loss?

If yes, please describe

Are you pregnant or recently gave birth?

Do you have a history of gastrointestinal issues that affect nutrient absorption, such as celiac disease, Crohn's disease, or gastric bypass surgery?

Do you have any chronic medical conditions that may increase your risk for iron deficiency, such as chronic kidney disease, gastrointestinal disorders, or bleeding disorders?

If yes, please specify

Are you currently taking any medications that may affect iron absorption or cause gastrointestinal bleeding (e.g., antacids, proton pump inhibitors, NSAIDs, blood thinners)?

If yes, please specify

Have you ever been diagnosed with iron deficiency or anemia in the past?

If yes, were you treated with Iron Supplements?

If yes, which iron supplements have you used?

What is your full name?

What is your phone number?

What is your Alberta Health ID?

What is your email?

Iron Infusion Assessment Form

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