Metabolic Form Page

Do any of the following situations apply to you?

Pregnant, planning on becoming pregnant, currently breastfeeding, or bottle-feeding with breastmilk

History of active, suspected, or prior cancer of any kind

Not had a general health check up or routine physical in the past 3 years

None of the above

Please select at least one option

Are you currently taking or have recently (within the last 1 month) taken any of the following medications?

NAD

Sermorelin

B12-MIC

Methylene blue

Glutathione

L-carnitine

Lipo-C

None of the above

Please select at least one option

Do you have any allergies or sensitivities?

Yes, to NAD

Yes, to sermorelin

Yes, to vitamin B12

Yes, to methionine

Yes, to inositol

Yes, to choline

Yes, to methylene blue

Yes, to thiazine dye

Yes, to glutathione

Yes, to L-carnitine

None of the above

Please select at least one option

Assuming clinical eligibility for NAD, do any of the following apply to you?

I prefer NAD via subcutaneous injection

I prefer NAD via nasal spray

I do not have a preference

Please select an option

Do any of the following situations apply to you?

Personal or family history of G6PD (glucose-6-phosphate dehydrogenase) deficiency

Elevated prolactin levels

Elevated IGFR (insulin-like growth factor) levels

Uncontrolled diabetes with a hemoglobin A1C greater than 9%

Binge drinking (4-5+ drinks on occasion per CDC guidelines)

Routine use of opiate medications

Hypothyroidism or take medications such as levothyroxine, Synthroid, NaturThyroid, Armour Thyroid, or Cytomel

Seizure disorder

Asthma or COPD

Use of serotonergic medications (many antidepressants, pain medications, or migraine medications) in the last 6 months

Kidney disease

Liver disease

Methylenetetrahydrofolate reductase (MTHFR) deficiency

Bipolar disorder

None of the above

Please select at least one option

Do you have any one of the following medical conditions?

Diabetes with a hemoglobin A1C less than 9%

Hypertension (high blood pressure)

Heart disease

Anxiety/depression

HIV or AIDS

Kidney disease

Liver disease

Irregular heart rate

Vascular disease (stroke, blood clots, etc)

None of the above

Please select at least one option

What Is Your Address?

Address Line 1 is required

City is required

State is required

Please enter a valid 5-digit ZIP code

Please list your current medications (prescription and over-the-counter) and supplements.

This field is required

Please select the U.S. state you are currently located in

Please select your state

Do you have any past trauma or conditions that would affect your ability to use a nasal spray?

Yes

No

Please select an option

It is important to note that clinicians can only make decisions based on the information provided to them. To that end, it is critical that the details provided and questions answered (for example, medication history) are complete and accurate. Do you agree to answer all questions completely and accurately?

Yes

No

Please select an option

Please make a product selection.

Not Eligible

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