NINE OR MORE PRESCRIPTION MEDICATIONS Unique ID Client InformationYour First Name*Your Last Name*Your Email Address Your Phone NumberEnter Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Lifestyle InformationDo you have kidney conditions?YesNoDo you smoke more than twice a week?YesNoOn a normal day, do you consume more than two cups of caffeinated beverages?YesNoOn average, do you consume more than one serving of alcohol per day?YesNo Prescription Medications MedsEnter your first prescription medication and strength, then click the "+" sign on the right to add more rows for other prescription medications.MedicationStrength Over-The-Counter Medication If yes, there are 8 classes of over-the-counter medications that deplete nutrients. Include in the analysis (by clicking yes) if listed below.Are you taking Over-The-Counter medications more than 5 times a week?YesNoRequirements MUST take over-the-counter medication more than 5 days a week MUST be in one of the following classesProton Pump InhibitorYesNoH2 AntagonistYesNoAntacidsYesNoCommon Examples: Omeprazole (Prilosec) Esmoeprazole (Nexium) Lansoprazole (Prevacid) Omeprazole (Prilosec) Pantoprazole (Protonix) Dexlansprazole (Kapidex)Common Examples: Cimetidine (Tagamet) Ranitidine (Zantac) Famotidine (Pepcid) Nizatidine (Axid)Common Examples: Sodium Bicarbonate (Alka Seltzer) Aluminum-Magnesium Antacids (Maalox) Aluminum Based Antacids (Amphojel) Alginic Acid (Gaviscon) Calcium Carbonate (Tums)NSAIDYesNoAspirinYesNoBisacodylYesNoCommon Examples: naproxen (Anaprox, Naprosyn) ibuprofen (Advil)Common Examples: Bayer Ecotrin BufferinCommon Examples: Dulcolaxc Correctol Bisacolax Bisac-evac Alophen Fleet Bisacodyl Feen-a-mintAcetaminophenYesNoNasal SpraysYesNo Common Examples: Tylenol Paracetamol Panadol MapapCommon Examples: Triamcinalone (Nasacort) Budesonide (Rhinocort) Fcuticasone (Clarispray, Flonase) BalancingMeds Terms and ServicesHIPPAIn 1996, the U.S. Congress passed The Health Insurance Portability and Accountability Act (“HIPAA”) to protect the privacy of patient health information. HIPAA prohibits health care providers from releasing patient health care information unless the patient has signed a HIPAA release form. By checking the box yes herein, you certify that you have obtained a signed release form from the patient for whom you are requesting a LifetimeAnalysis™. Click here to print a HIPPA Release Form.YesNoBalancingMeds DisclaimerI understand that BalancingMeds.com and its content is not intended to treat, diagnose, or cure any disease or ailment. The information derived using BalancingMeds should be used on an informational basis to help guide clinical decision-making (please click the link below to read the entire statement before you agree..) I have read and agree to the BalancingMeds™ Disclaimer statement.YesNoConsenting AdultAt this time, the BalancingMeds™ Analysis is available only for application to people eighteen years of age and older, who have the ability to consent. By checking this box yes, you certify that your client is a minimum of eighteen years old and has the ability to consent.YesNoPregnancy or LactatingAt this time, the BalancingMeds™ Analysis does not analyze the unique factors associated with pregnancy. By checking this box yes, you certify your client is not pregnant.YesNoAnalysis FeeThis page is unsecured. Do not enter a real credit card number! Use this field only for testing purposes. Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.