MANAGE YOUR MEDICATION RISKS

myPillHelp™

Provided by our Doctors of Pharmacy

The fee for this service is $195.


Our mantra is PillHelp Protects!

MyPillHelp is a way to learn the truth about your medicines. how to manage the risks, avoid harm, and control waste. Requesting our services is empowering.

Remember any changes should be made with guidance from both pharmacist and physician. That will insure the best outcomes.

Please complete this form. We will make every effort to return your assessment within 72 hours. Fill in only the information that applies to you and leave other fields blank. If you prefer, you can print this form, fill in the data manually and email it to DrDon@PillHelp.com, or mail it to:

PillHelp, Inc.
8191 Breton Circle
Fort Myers, FL. 33912

FREQUENTLY ASKED QUESTIONS

You will be asked for credit card payment when you submit the form. There are no other charges, or fees. There is no obligation to continue service with the PillHelp, Inc., however for your best health, you are encouraged to reach out to us any time .

If you have any questions, please contact us.


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I am unable to receive phone calls.

Information About Yourself
E-mail(required):
First Name:
Last Name:
Address:
City:  
State:  
Country:  
Zip:  
Home Phone:  
Work Phone:  
Date of Birth:  
Race:  
Gender: Male Female  

Question or Problem:

Occupation or Primary Activity:

Your Primary or Family Physician
Name:
Specialty:
Address:
City:
State:
Zip:
Phone:

Specialist Physician
Name:
Specialty:
Address:
City:
State:
Zip:
Phone:

Specialist Physician
Name:
Specialty:
Address:
City:
State:
Zip:
Phone:

Height ft. in.
Weight lbs.

Your Illnesses - Check all that apply


High Blood Diabetes Female Hormones Male Hormones
Cholesterol HYPOglycemia Weight Worries Nausea
Stroke Heaches, frequent Water retention Diarrhea
Memory Heaches, infrequent Muscle aches, frequent Constipation
Chronic pain Asthma Muscle aches, every day Arthritis
Skin Problems (not allergy) Emphysema Cancer HIV / AIDS
Allergies COPD (or other breathing problems) Emotional Illness Dental problems
Thyroid Hysterectomy Psychological illness Prostate
Ulcer, stomach Polyps Alzheimer's Liver
Reflux Glaucoma Dizziness Kidneys
Ulcer, bowel Macular degeneration Hearing Anemia
Bleeding or clotting Cataracts Transplant Shingles
Frequent infections (more than 3 per year) Anxiety Addiction and dependence Addiction, in recovery
Seizure disorder Sleep too much Spinal Cord Frequent Urinary Tract infections
Head trauma Sleep too little Parkinson's Urinary frequency
TB Endometriosis MS or Dystrophy Erectile Dysfunction
Fertility issues Menstrual problems Libido concerns Kidney stones
Pregnant         Dialysis

Allergies, and Bad or Uncomfortable Reactions:

Please include drugs, chemicals, foods, environmental and airborne materials. Please indicate your reaction as well as the substance.

Drug Allergies or Reactions to Drugs:

Allergies or Reactions to Foods (Including Food Additives):

Allergies or Reactions to Environmental Substances (Includes inhaled fumes, pollen) or Skin Reactions:

What Prescription Medications Are You Currently Taking?:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Name of Medication:
Strength of Dosage:
Doctor for this prescription:
Directions:

Over-the-counter medications you have on hand:

Medication 1:
Medication 2:
Medication 3:
Medication 4:
Medication 5:
Medication 6:

Vitamins you have on hand:

Vitamin 1:
Vitamin 2:
Vitamin 3:
Vitamin 4:
Vitamin 5:
Vitamin 6:

Herbs being consumed:

Herb 1:
Herb 2:
Herb 3:
Herb 4:
Herb 5:
Herb 6:

Life Style:

Smoking:

Exercise types (example - rowing,jogging, lifting, situps, etc.):

Frequency:

Your usual sources of Prescription Medication:

Source 1
Company Name:
Address:
City:
State:
Phone:
Source 2
Company Name:
Address:
City:
State:
Phone:
Source 3
Company Name:
Address:
City:
State:
Phone:

Backup Contact Person:

Name:
Phone Number:
E-mail Address (if known):

Is there any other information you think we should know?:

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