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  • LIMITED FORMS
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  • Client Information



  • Lifestyle Information



  • Conditions Treated

  • Add a row Remove this row
    Please enter the chief complaint being treated. Enter one condition
    per entry box, and add more boxes with the + icon to the right.


  • Prescription Medication


  • Please enter the number of the prescription medications your client is currently taking.

  • Please enter one prescription medication and one medication strength per row. As you type the prescription medication name, it will auto-suggest the correct spelling. Hit the down arrow on your keyboard or click in another box to let the system know you've chosen your medication.
    For example: Abilify            16mg


  • Over-The-Counter Medication

  • Requirements
    • MUST take over-the-counter medication more than 5 times a week
    • MUST be in one of the following classes
  • Common Examples:
    Omeprazole (Prilosec)
    Esmoeprazole (Nexium)
    Lansoprazole (Prevacid)
    Omeprazole (Prilosec)
    Pantoprazole (Protonix)
    Dexlansprazole (Kapidex)
  • Common Examples:
    Cimetidine (Tagamet)
    Ranitidine (Zantac)
    Famotidine (Pepcid)
    Nizatidine (Axid)
  • Common Examples:
    Sodium Bicarbonate (Alka Seltzer)
    Aluminum-Magnesium Antacids (Maalox)
    Aluminum Based Antacids (Amphojel)
    Alginic Acid (Gaviscon)
    Calcium Carbonate (Tums)

  • Common Examples:
    naproxen (Anaprox, Naprosyn)
    ibuprofen (Advil)
  • Common Examples:
    Bayer
    Ecotrin
    Bufferin
  • Common Examples:
    Dulcolaxc
    Correctol
    Bisacolax
    Bisac-evac
    Alophen
    Fleet Bisacodyl
    Feen-a-mint

  •  
  •  
  • Common Examples:
    Tylenol
    Paracetamol
    Panadol
    Mapap

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