Intake Form

Patient Details

Date of Birth:*
Time Zone:*

Primary Care Physician Details

Physician Name:
Physician Phone:

LDN Use History

Have you used LDN before?*
Did your doctor previously prescribe LDN because:*
How long have you been taking LDN?*
What dose of LDN have you been using?*
How well has LDN worked for you?
Has your previous / existing use of LDN resulted in any side effects?*
Please describe the side effects you have experienced:*

Medical History

Please provide a list of disorders / symptoms you have been diagnosed with or are experiencing:*
Please list any family history of chronic or serious disease:
Please list any allergies to food and/or medications of which you are aware:
Please list all current medications and food supplements you are taking:
Are you taking any opiate-type pain medication?*
Please note: In general it is not advisable to use LDN with opiates, as LDN can cancel the pain-relieving effects of opiates. In some cases, lower doses of LDN can improve the pain-relieving effects of opiates. Please proceed with booking your appointment only if you realize we may be unable to prescribe regular doses of LDN while you are using opiates.
Please specify all current opiate-type pain medication you are taking:*
Please list any major abnormalities in your blood test that you are aware of:
Are you seeking LDN for controlling alcohol or substance craving?*
Please note that alcohol and substance craving usually needs regular-dose naltrexone treatment, which we do NOT provide. While there have been no formal studies with LDN (i.e. below 5mg per day), some users report decreased craving. Please proceed with booking your appointment only if you realize we can provide prescriptions for low dose naltrexone but not for regular-dose naltrexone.

How did you hear about LDNdoctor?

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