Testform - Peaks Curative

Patient Name

First

Middle

Last

What was your sex assigned at birth?

Male
Female

Date of Birth

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Online Treatment Agreement

I understand that an online medical visit can be a great option for minor medical issues and not ideal for severe or life-threatening illnesses. I understand that treatment offered by prescribers of Peaks Curative is on the basis of clinical judgment, in the absence of a complete physical examination. I agree to follow up with a doctor for in-person evaluation or seek emergency care if my symptoms worsen or do not improve in a timely manner.

I am capable of making sound medical decisions

Yes
No

Do you have an allergy to a particular medication, supplement, mineral or vitamin?

Yes, I have a history of drug allergies
No known drug allergies

How physically active are you?

Sedentary (no physical activity)
Somewhat Active (90 minutes of physical activity per week)
Active (at least 5 hours of physical activity per week)
Very Active (5+ hours of physical activity per week)
Extremely Active (7+ hours of intense physical activity per week)

Do you take any prescription medications?

Yes
No

Do you have any medical conditions?

Yes (Anything you see a doctor or take medication for.)
No

Have you had any injuries or surgeries within the last 6 months?

Yes
No

Any known history of B-12 deficiency or absorption issues?

Yes
No

Do any of the following apply to you?

Hypothyroidism
Glioma
Any type of cancer or tumor
None of these

Do you take any of the following medications? (Select all that apply)

Propylthiouracil
Clonidine or Levodopa
Octreotide, lanreotide, or pasireotide
Glucocorticoids (such as prednisone, dexamethasone)
COX inhibitors (Aspirin, Advil, Celebrex, or similar)
None of these

When was the last time you had an in person medical evaluation including laboratory tests?

Less than a year ago.
1 to 2 years ago.
More than 2 years ago.

Please select all that apply. (This question is required to evaluate the safety of your prescription. Your answers are confidential and protected by federal law under HIPAA. We cannot and do not disclose any information from your answers).

I drink 4 or more alcoholic drinks at a time per day.
I take opiates (prescription or recreational)
Both apply to me
None apply to me

Are you pregnant, planning to become pregnant, or currently breastfeeding?

Yes
No

Patient Assertation

I attest that I am the patient identified at the top of this form and that I am completing this questionnaire truthfully and of my own free will for my personal medical care. I understand that the information I provide will be reviewed by a licensed healthcare provider for the purpose of determining whether a prescription is appropriate.

Medication Disclosure Clause

I hereby agree to indemnify and hold harmless the reviewing prescriber and/or employees of the prescriber harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication of any other vital medical information.

Prescription will be fulfilled by RxCompoundStore.com.

Yes, I agree

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