Provider Title LA Type Provider First Last Provider PhoneProvider Email Unique IDEnter Your Information Client First Name Client Last Name Client Email Client PhoneClient Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 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 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 Strength Medication 2 InformationMedication 2 NameMedication 2 Strength Medication 3 InformationMedication 3 NameMedication 3 Strength End Medication 3Medication 4 InformationMedication 4 NameMedication 4 Strength End Medication 4Begin Medication 5Medication 5 NameMedication 5 Strength End Medication 5Begin Medication 6Medication 6 NameMedication 6 Strength End Medication 6Begin Medication 7Medication 7 NameMedication 7 Strength End Medication 7Begin Medication 8Medication 8 NameMedication 8 Strength End Medication 8Begin Medication 9Medication 9 NameMedication 9 Strength End Medication 9Begin Medication 10Medication 10 NameMedication 10 Strength End Medication 10Begin Medication 11Medication 11 NameMedication 11 Strength End Medication 11Begin Medication 12Medication 12 NameMedication 12 Strength End Medication 12Begin Medication 13Medication 13 NameMedication 13 Strength End Medication 13Begin Medication 14Medication 14 NameMedication 14 Strength End Medication 14Begin Medication 15Medication 15 NameMedication 15 Strength End Medication 15Begin Medication 16Medication 16 NameMedication 16 Strength End Medication 16Begin Medication 17Medication 17 NameMedication 17 Strength End Medication 17Begin Medication 18Medication 18 NameMedication 18 Strength End Medication 18Begin Medication 19Medication 19 NameMedication 19 Strength End Medication 19Begin Medication 20Medication 20 NameMedication 20 Strength End Medication 20Begin Medication 21Medication 21 NameMedication 21 Strength End Medication 21Begin Medication 22Medication 22 NameMedication 22 Strength End Medication 22Begin Medication 23Medication 23 NameMedication 23 Strength End Medication 23Begin Medication 24Medication 24 NameMedication 24 Strength End Medication 24Begin Medication 25Medication 25 NameMedication 25 Strength End Medication 25Begin Medication 26Medication 26 NameMedication 26 Strength End Medication 26Begin Medication 27Medication 27 NameMedication 27 Strength End Medication 27Begin Medication 28Medication 28 NameMedication 28 Strength End Medication 28Begin Medication 29Medication 29 NameMedication 29 Strength End Medication 29Begin Medication 30Medication 30 NameMedication 30 Strength End Medication 30Begin Medication 31Medication 31 NameMedication 31 Strength End Medication 31Begin Medication 32Medication 32 NameMedication 32 Strength End Medication 32Begin Medication 33Medication 33 NameMedication 33 Strength End Medication 33Begin Medication 34Medication 34 NameMedication 34 Strength End Medication 34Begin Medication 35Medication 35 NameMedication 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 MedicationProton Pump InhibitorCommon Examples: Omeprazole (Prilosec) Esmoeprazole (Nexium) Lansoprazole (Prevacid) Omeprazole (Prilosec) Pantoprazole (Protonix) Dexlansprazole (Kapidex) Yes No H2 AntagonistCommon Examples: Cimetidine (Tagamet) Cimetidine (Tagamet HB) Ranitidine (Zantac) Ranitidine (Zantac 150) Famotidine (Pepcid) Nizatidine (Axid) Yes No AntacidsCommon Examples: Sodium Bicarbonate (Alka Seltzer) Aluminum-Magnesium Antacids (Maalox) Aluminum Based Antacids (Amphojel) Alginic Acid (Gaviscon) Calcium Carbonate (Rolaids) Calcium Carbonate (Tums) Yes No NSAIDCommon Examples: Fenoprofen calcium (Nalfon) Naproxen (Anaprox, Naprosyn) Ibuprofen (Advil, Motrin) Celecoxib (Celebrex) Tolmetin sodium (Tolectin) Diflunisal (Dolobid) Yes No AspirinCommon Examples: Anacin Ascriptin Bayer Bufferin Ecotrin Excedrin Yes No BisacodylCommon Examples: Dulcolaxc Correctol Bisacolax Bisac-evac Alophen Fleet Bisacodyl Yes No AcetaminophenCommon 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 LifetimeAnalysis Disclaimer | Terms & Services | HIPPA
