Customer Medication Request

    1. Is there anything in your medical history that you consider to be relevant? If yes, please specify. Enter “NONE” if none. None I will specify   2. Please list all current medical conditions. Enter “NONE” if none. None I will specify   3. Please list all medications that you plan to take while on this program. Enter “NONE” if none. None I will specify   4. Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each. Enter “NONE” if none. None I will specify   5. Please list all past or present allergies including allergies to any medications. Enter “NONE” if none. None I will specify   6. Please list all past surgeries and provide details including the condition that was treated with each surgery. Enter “NONE” if none. None I will specify   7. Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. This cannot be left blank.  

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