List To Wiz 2 Provider TitleLA TypeProvider First Last Provider PhoneProvider Email Unique IDClient Information Client First NameClient Last NameClient Email Client PhoneClient Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Lifestyle Information Does client have kidney conditions?YesNoWhat is your client's gender?FemaleMaleDoes your client regularly smoke tobacco?YesNoAverage more than two caffeinated beverages per day?YesNoAverage more than one serving of alcohol per day?YesNo Conditions Being Treated Conditions Being Treated Client Prescription Information Number of Prescription MedicationsPlease Select1234567891011121314151617181920212223242526272829303132333435Medication 1 InformationPlease enter the name and prescribed strenght of each medication. For instance: Medication 1 Name = Zocor and Medication 1 Strength = 10 mg.Medication 1 Name Medication 1 StrengthMedication 2 InformationMedication 2 Name Medication 2 StrengthMedication 3 InformationMedication 3 Name Medication 3 StrengthEnd Medication 3Medication 4 InformationMedication 4 Name Medication 4 StrengthEnd Medication 4Begin Medication 5Medication 5 Name Medication 5 StrengthEnd Medication 5Begin Medication 6Medication 6 Name Medication 6 StrengthEnd Medication 6Begin Medication 7Medication 7 Name Medication 7 StrengthEnd Medication 7Begin Medication 8Medication 8 Name Medication 8 StrengthEnd Medication 8Begin Medication 9Medication 9 Name Medication 9 StrengthEnd Medication 9Begin Medication 10Medication 10 Name Medication 10 StrengthEnd Medication 10Begin Medication 11Medication 11 Name Medication 11 StrengthEnd Medication 11Begin Medication 12Medication 12 Name Medication 12 StrengthEnd Medication 12Begin Medication 13Medication 13 Name Medication 13 StrengthEnd Medication 13Begin Medication 14Medication 14 Name Medication 14 StrengthEnd Medication 14Begin Medication 15Medication 15 Name Medication 15 StrengthEnd Medication 15Begin Medication 16Medication 16 Name Medication 16 StrengthEnd Medication 16Begin Medication 17Medication 17 Name Medication 17 StrengthEnd Medication 17Begin Medication 18Medication 18 Name Medication 18 StrengthEnd Medication 18Begin Medication 19Medication 19 Name Medication 19 StrengthEnd Medication 19Begin Medication 20Medication 20 Name Medication 20 StrengthEnd Medication 20Begin Medication 21Medication 21 Name Medication 21 StrengthEnd Medication 21Begin Medication 22Medication 22 Name Medication 22 StrengthEnd Medication 22Begin Medication 23Medication 23 Name Medication 23 StrengthEnd Medication 23Begin Medication 24Medication 24 Name Medication 24 StrengthEnd Medication 24Begin Medication 25Medication 25 Name Medication 25 StrengthEnd Medication 25Begin Medication 26Medication 26 Name Medication 26 StrengthEnd Medication 26Begin Medication 27Medication 27 Name Medication 27 StrengthEnd Medication 27Begin Medication 28Medication 28 Name Medication 28 StrengthEnd Medication 28Begin Medication 29Medication 29 Name Medication 29 StrengthEnd Medication 29Begin Medication 30Medication 30 Name Medication 30 StrengthEnd Medication 30Begin Medication 31Medication 31 Name Medication 31 StrengthEnd Medication 31Begin Medication 32Medication 32 Name Medication 32 StrengthEnd Medication 32Begin Medication 33Medication 33 Name Medication 33 StrengthEnd Medication 33Begin Medication 34Medication 34 Name Medication 34 StrengthEnd Medication 34Begin Medication 35Medication 35 Name Medication 35 StrengthEnd Medication 35 Client Over-The-Counter Information Is client taking Over-The-Counter medications more than 5 times a week?YesNoOver-The-Counter MedicationProton Pump InhibitorCommon Examples: Omeprazole (Prilosec) Esmoeprazole (Nexium) Lansoprazole (Prevacid) Omeprazole (Prilosec) Pantoprazole (Protonix) Dexlansprazole (Kapidex)YesNoH2 AntagonistCommon Examples: Cimetidine (Tagamet) Cimetidine (Tagamet HB) Ranitidine (Zantac) Ranitidine (Zantac 150) Famotidine (Pepcid) Nizatidine (Axid)YesNoAntacidsCommon Examples: Sodium Bicarbonate (Alka Seltzer) Aluminum-Magnesium Antacids (Maalox) Aluminum Based Antacids (Amphojel) Alginic Acid (Gaviscon) Calcium Carbonate (Rolaids) Calcium Carbonate (Tums)YesNoNSAIDCommon Examples: Fenoprofen calcium (Nalfon) Naproxen (Anaprox, Naprosyn) Ibuprofen (Advil, Motrin) Celecoxib (Celebrex) Tolmetin sodium (Tolectin) Diflunisal (Dolobid) YesNoAspirinCommon Examples: Anacin Ascriptin Bayer Bufferin Ecotrin ExcedrinYesNoBisacodylCommon Examples: Dulcolaxc Correctol Bisacolax Bisac-evac Alophen Fleet BisacodylYesNoAcetaminophenCommon Examples: Tylenol Paracetamol Panadol Mapap Excedrin Back and Body Pain Aid YesNoEnd Over-The-Counter Medication LifetimeAnalysis Terms and Conditions I Agree To LifetimeAnalysis Terms and ServicesYesNoLifetimeAnalysis Disclaimer | Terms & Services | HIPPA
