Nasal Spray Medical Intake Form
Do you live in one of these states: Arizona, California, Connecticut, Florida, Illinois, Massachusetts, New Jersey, New Mexico, New York, Texas, Utah, Virginia, Colorado, and Wisconsin.
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Yes I live in one of these states
I dont live in one of these states
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOB
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Please list all medications currently being taken- dosage not needed. If you do not take any medication write "none."
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If you have any medication allergies, please write them in the box below. If none please write "none."
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Are you currently pregnant, trying to become pregnant, or breastfeeding? Or, if applicable, is there any chance you could become pregnant during the time you would be using this medication?
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No
Yes
Do you have any of the following heart or blood pressure conditions: high blood pressure, low blood pressure, irregular heartbeat or arrhythmia, history of heart attack, heart failure, fainting episodes, or any other cardiovascular disease?
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No
Yes
Unsure
Have you ever been diagnosed with, or do you currently have, any of the following: schizophrenia, schizoaffective disorder, bipolar disorder, psychotic episodes, severe borderline personality disorder, or any other psychiatric condition for which you are currently hospitalized or in crisis treatment?
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No
Yes
Do you have any of the following: kidney disease, low sodium levels (hyponatremia), syndrome of inappropriate antidiuretic hormone (SIADH), or have you ever had seizures related to fluid or electrolyte imbalance?
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No
Yes
Are you allergic to oxytocin, chlorobutanol, or any preservative or excipient commonly used in compounded nasal sprays? Have you ever had a severe reaction (rash, swelling, breathing problems) to a nasal spray or compounded medication?
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No
Yes
Are you currently taking any of the following medications? Mark all that apply.
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Please Select
Migraine medication with ergot or ergotamine
Lithium
Vasoconstrictors or decongestant
Diuretics or "water pill"
None of the above
Do you have any current nasal or sinus conditions, including chronic rhinitis, nasal polyps, deviated septum, recent nasal surgery (within the past 6 months), frequent nosebleeds, or active sinus infection?
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No
Yes
Have you ever been diagnosed with a substance use disorder, or are you currently in active treatment or recovery for alcohol or drug dependency?
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No
Yes in the past
Yes currently
Prefer not to answer
Submit
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