Provider TitleLA TypeProvider First Last Provider PhoneProvider Email Unique IDEnter Your Information Client First NameClient Last NameClient Email Client PhoneClient Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 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 NameMedication 1 StrengthMedication 2 InformationMedication 2 NameMedication 2 StrengthMedication 3 InformationMedication 3 NameMedication 3 StrengthEnd Medication 3Medication 4 InformationMedication 4 NameMedication 4 StrengthEnd Medication 4Begin Medication 5Medication 5 NameMedication 5 StrengthEnd Medication 5Begin Medication 6Medication 6 NameMedication 6 StrengthEnd Medication 6Begin Medication 7Medication 7 NameMedication 7 StrengthEnd Medication 7Begin Medication 8Medication 8 NameMedication 8 StrengthEnd Medication 8Begin Medication 9Medication 9 NameMedication 9 StrengthEnd Medication 9Begin Medication 10Medication 10 NameMedication 10 StrengthEnd Medication 10Begin Medication 11Medication 11 NameMedication 11 StrengthEnd Medication 11Begin Medication 12Medication 12 NameMedication 12 StrengthEnd Medication 12Begin Medication 13Medication 13 NameMedication 13 StrengthEnd Medication 13Begin Medication 14Medication 14 NameMedication 14 StrengthEnd Medication 14Begin Medication 15Medication 15 NameMedication 15 StrengthEnd Medication 15Begin Medication 16Medication 16 NameMedication 16 StrengthEnd Medication 16Begin Medication 17Medication 17 NameMedication 17 StrengthEnd Medication 17Begin Medication 18Medication 18 NameMedication 18 StrengthEnd Medication 18Begin Medication 19Medication 19 NameMedication 19 StrengthEnd Medication 19Begin Medication 20Medication 20 NameMedication 20 StrengthEnd Medication 20Begin Medication 21Medication 21 NameMedication 21 StrengthEnd Medication 21Begin Medication 22Medication 22 NameMedication 22 StrengthEnd Medication 22Begin Medication 23Medication 23 NameMedication 23 StrengthEnd Medication 23Begin Medication 24Medication 24 NameMedication 24 StrengthEnd Medication 24Begin Medication 25Medication 25 NameMedication 25 StrengthEnd Medication 25Begin Medication 26Medication 26 NameMedication 26 StrengthEnd Medication 26Begin Medication 27Medication 27 NameMedication 27 StrengthEnd Medication 27Begin Medication 28Medication 28 NameMedication 28 StrengthEnd Medication 28Begin Medication 29Medication 29 NameMedication 29 StrengthEnd Medication 29Begin Medication 30Medication 30 NameMedication 30 StrengthEnd Medication 30Begin Medication 31Medication 31 NameMedication 31 StrengthEnd Medication 31Begin Medication 32Medication 32 NameMedication 32 StrengthEnd Medication 32Begin Medication 33Medication 33 NameMedication 33 StrengthEnd Medication 33Begin Medication 34Medication 34 NameMedication 34 StrengthEnd Medication 34Begin Medication 35Medication 35 NameMedication 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