Please Choose a Pharmacist

Please choose from the list below to serve you, if you would like to see a list of all our participating pharmacists, click here. Select a Pharmacist Richard Marasco Joshua Neff Suzette Robine Donald Thibodeau Thane VanEaton Carol Young

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Information About Yourself
E-mail:
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:

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:
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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:

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What Prescription Medications Are You Currently Taking?:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
Directions:

Name of Medication:
Strength of Dosage:
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: none light moderate heavy

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

Frequency: Daily Weekly Infrequently Never

Insurance (Leave blank at this time.):

Primary Provider:
Provider Telephone Number:
Group Number:
Member ID Number:
Insurance Provided By (employer):
Location:

Backup Contact Person:

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

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