REQUEST ANALYSIS | BalancingMeds

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- MEDICATION WEIGHT GAIN
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Provider Title
LA Type
Provider
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Provider Email
Unique ID
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Client First Name
Client Last Name
Client Email
Client Phone
Client Date of Birth
Lifestyle Information
Does client have kidney conditions?
- Yes
- No
What is your client's gender?
- Female
- Male
Does your client regularly smoke tobacco?
- Yes
- No
Average more than two caffeinated beverages per day?
- Yes
- No
Average more than one serving of alcohol per day?
- Yes
- No
Conditions Being Treated
Conditions Being Treated
Client Prescription Information
Number of Prescription Medications
Medication 1 Information
Please 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 Strength
Medication 2 Information
Medication 2 Name
Medication 2 Strength
Medication 3 Information
Medication 3 Name
Medication 3 Strength
End Medication 3
Medication 4 Information
Medication 4 Name
Medication 4 Strength
End Medication 4
Begin Medication 5
Medication 5 Name
Medication 5 Strength
End Medication 5
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Medication 6 Name
Medication 6 Strength
End Medication 6
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Medication 7 Name
Medication 7 Strength
End Medication 7
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Medication 8 Name
Medication 8 Strength
End Medication 8
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Medication 9 Name
Medication 9 Strength
End Medication 9
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Medication 10 Name
Medication 10 Strength
End Medication 10
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Medication 11 Name
Medication 11 Strength
End Medication 11
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Medication 12 Name
Medication 12 Strength
End Medication 12
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Medication 13 Name
Medication 13 Strength
End Medication 13
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Medication 14 Name
Medication 14 Strength
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Medication 15 Name
Medication 15 Strength
End Medication 15
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Medication 16 Name
Medication 16 Strength
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Medication 17 Name
Medication 17 Strength
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Medication 18 Name
Medication 18 Strength
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Medication 19 Name
Medication 19 Strength
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Medication 20 Name
Medication 20 Strength
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Medication 21 Name
Medication 21 Strength
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Medication 22 Name
Medication 22 Strength
End Medication 22
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Medication 23 Name
Medication 23 Strength
End Medication 23
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Medication 24 Name
Medication 24 Strength
End Medication 24
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Medication 25 Name
Medication 25 Strength
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Medication 26 Name
Medication 26 Strength
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Medication 27 Name
Medication 27 Strength
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Medication 28 Name
Medication 28 Strength
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Medication 29 Name
Medication 29 Strength
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Medication 30 Name
Medication 30 Strength
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Medication 31 Name
Medication 31 Strength
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Medication 32 Name
Medication 32 Strength
End Medication 32
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Medication 33 Name
Medication 33 Strength
End Medication 33
Begin Medication 34
Medication 34 Name
Medication 34 Strength
End Medication 34
Begin Medication 35
Medication 35 Name
Medication 35 Strength
End Medication 35
Client Over-The-Counter Information
Is client taking Over-The-Counter medications more than 5 times a week?
- Yes
- No
Over-The-Counter Medication
Proton Pump Inhibitor
Common Examples:
Omeprazole (Prilosec)
Esmoeprazole (Nexium)
Lansoprazole (Prevacid)
Omeprazole (Prilosec)
Pantoprazole (Protonix)
Dexlansprazole (Kapidex)
- Yes
- No
H2 Antagonist
Common Examples:
Cimetidine (Tagamet)
Cimetidine (Tagamet HB)
Ranitidine (Zantac)
Ranitidine (Zantac 150)
Famotidine (Pepcid)
Nizatidine (Axid)
- Yes
- No
Antacids
Common Examples:
Sodium Bicarbonate (Alka Seltzer)
Aluminum-Magnesium Antacids (Maalox)
Aluminum Based Antacids (Amphojel)
Alginic Acid (Gaviscon)
Calcium Carbonate (Rolaids)
Calcium Carbonate (Tums)
- Yes
- No
NSAID
Common Examples:
Fenoprofen calcium (Nalfon)
Naproxen (Anaprox, Naprosyn)
Ibuprofen (Advil, Motrin)
Celecoxib (Celebrex)
Tolmetin sodium (Tolectin)
Diflunisal (Dolobid)
- Yes
- No
Aspirin
Common Examples:
Anacin
Ascriptin
Bayer
Bufferin
Ecotrin
Excedrin
- Yes
- No
Bisacodyl
Common Examples:
Dulcolaxc
Correctol
Bisacolax
Bisac-evac
Alophen
Fleet Bisacodyl
- Yes
- No
Acetaminophen
Common Examples:
Tylenol
Paracetamol
Panadol
Mapap
Excedrin Back and Body
Pain Aid
- Yes
- No
End Over-The-Counter Medication
LifetimeAnalysis Terms and Conditions
I Agree To LifetimeAnalysis Terms and Services
- Yes
- No
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Lifestyle Information

Conditions Being Treated

Client Prescription Information

Medication 1 Information

Medication 2 Information

Medication 3 Information

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Client Over-The-Counter Information

Over-The-Counter Medication

End Over-The-Counter Medication

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