Online Prescription Assessment
Personal Details
1.
Name
2.
What is your biological sex?
Male
Female
3.
Address
4.
What is your date of birth?
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
5.
What is your height?
6.
What is your weight
7.
Dosage of medication
Medication prescribed by US Doctor
8.
Reason for requiring medication
9
Name of the prescribing doctor?
10.
Have you used this medication before?
No
Yes
11.
Are you taking any other medication?
No
Yes
12.
Do you suffer from any other conditions?
No
Yes
13.
Are you allergic to any substances, any medicine or food products?
No
Yes
14.
BMI (If known)
No
Yes
15.
Upload original RX
jpg, png, pdf file supported
16.
Do you have Type 1 diabetes mellitus?
No
Yes
17.
Do you have any history of medullary thyroid cancer?
No
Yes
18.
Do you have history or family history of endocrine neoplasia?
No
Yes
19.
Do you have any history of pancreatitis?
No
Yes
20.
Do you have any liver or kidney impairment?
No
Yes
21.
Do you have any history of gastrointestinal illness such as gateoparesis or malabsorption?
No
Yes
22.
Are you pregnant or breastfeeding?
No
Yes
23.
Do you have any history of diabetic retinopathy (diabetes eye disease involving retina)?
No
Yes
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