Intake Form Patient DetailsName:* First Last Gender:*Select valueMaleFemaleAddress:* Street AddressStreet Address Line 2 (optional)CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone:* Area Code - Phone Number E-mail:*Date of Birth:*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 2021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearBodyweight:*Height:*Time Zone:*Select valueEST (UTC-5:00)CST (UTC-6:00)MST (UTC-7:00)PST (UTC-8:00)Alaska (UTC-9:00)Hawaii (UTC-10:00)Samoa (UTC-11:00)Atlantic (UTC-4:00)Chamorro (UTC+10:00)Primary Care Physician DetailsPhysician Name:Physician Phone: Area Code - Phone Number LDN Use HistoryHave you used LDN before?*Select valueYesNoDid your doctor previously prescribe LDN because:*Select valueYou asked for itThe doctor suggested itHow long have you been taking LDN?*Select value0-3 months4-6 months7-12 months1 year +What dose of LDN have you been using?*How well has LDN worked for you?Select valueExcellentVery wellWellFairlyNot Very WellHas your previous / existing use of LDN resulted in any side effects?*Select valueYesNoPlease describe the side effects you have experienced:*Medical HistoryPlease provide a list of disorders / symptoms you have been diagnosed with or are experiencing:*Please list any family history of chronic or serious disease:Relationship + conditionPlease 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?*Select valueYesNoPlease 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?*Select valueYesNoPlease 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?I heard about your service from: (check all that apply) A google searchA blogLDNdoctor's Facebook PageA Facebook groupA website about LDNYouTubeOtherWhich blog?Which group?Which website?Please specify: Please check the box below:SubmitReset