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Unique ID

Client Information

Client Name*

First Last

Client Email Address

Client Phone Number

Enter Date of Birth*

Lifestyle Information

Does client have kidney conditions?

Yes
No

Does client smoke?

Yes
No

Average more than two caffeinated beverages per day?

Yes
No

Average more than one serving of alcohol per day?

Yes
No

Conditions Treated

Enter Conditions Treated

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

Enter Number of Prescription Medications

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

Medication 1 Name

Medication 1 Strength

Medication 2 Name

Medication 2 Strength

Medication 3 Name

Medication 3 Strength

Over-The-Counter Medication

Is client taking Over-The-Counter medications more than 5 times a week?

Yes
No

Requirements

MUST take over-the-counter medication more than 5 times a week
MUST be in one of the following classes

Proton Pump Inhibitor

Yes
No

H2 Antagonist

Yes
No

Antacids

Yes
No

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)

NSAID

Yes
No

Aspirin

Yes
No

Bisacodyl

Yes
No

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

Acetaminophen

Yes
No

Common Examples:
Tylenol
Paracetamol
Panadol
Mapap

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HIPPA

YES
NO

Analysis Fee

Credit Card

American Express

Discover

MasterCard

Visa

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