Request a Consultation

Before completing the below form, please familiarize yourself with the How Does It Work? page, which outlines our fees and protocols.

We strongly encourage you to discuss any information provided to you through RxISK eCONSULT with your own doctor.

Medical Information and Consent Form

Terms & Conditions*
- I accept the RxISK eCONSULT Terms & Conditions and Privacy Policy.
- I am 18 years or older and I am under the care of a doctor or other medical professional.
Please click here to read the RxISK eCONSULT Terms & Conditions and Privacy Policy.
Name*
First Last
Email*
Enter Email Confirm Email
Location*
City Country
Age Your doctor's name Your doctor's specialty
What are your main medication concerns?
(Please provide as much information here as possible so we can better evaluate your situation.)
Describe your medical condition(s).
(Please provide as much information here as possible so we can better evaluate your situation.)
What is your estimate of your general health?
- Excellent
- Good
- Fair
- Poor
Have you ever experienced any of the following? (check all that apply)
- Q# 1. Hospitalization for illness or injury
- Q# 2. An allergic reaction to any prescription medicines
- Q# 3. An allergic reaction to any over the counter or herbal/complementary therapies
- Q# 4. An allergic reaction to any other agent
- Q# 5. Heart problems or cardiac stent
- Q# 6. Artificial prosthesis (heart valve or joints)
- Q# 7. Rheumatic or scarlet fever
- Q# 8. High or low blood pressure
- Q# 9. A stroke
- Q# 10. Anemia or other blood disorder
- Q# 11. Lung disease
- Q# 12. Tuberculosis
- Q# 13. Asthma
- Q# 14. Breathing or sleep problems (e.g., sleep apnea, snoring, sinus)
- Q# 15. Kidney disease
- Q# 16. Liver disease
- Q# 17. Jaundice
- Q# 18. Thyroid, parathyroid disease, or calcium deficiency
- Q# 19. Hormone deficiency
- Q# 20. Diabetes
- Q# 21. Stomach or duodenal ulcer
- Q# 22. Other digestive disorders
- Q# 23. Osteoporosis/osteopenia
- Q# 24. Arthritis
- Q# 25. Autoimmune disease (e.g., rheumatoid arthritis, lupus, scleroderma)
- Q# 26. Glaucoma
- Q# 27. Head or neck injuries
- Q# 28. Epilepsy, convulsions (seizures)
- Q# 29. Neurologic disorders
- Q# 30. Viral infections and cold sores
- Q# 31. Hives, skin rash, hay fever
- Q# 32. HIV/AIDS
- Q# 33. Tumour, abnormal growth
- Q# 34. Radiation therapy chemotherapy or immunosuppressive medication
- Q# 35. Emotional problems
- Q# 36. Non-drug psychiatric treatment
- Q# 37. Anti-depressant or other psychiatric drug medication
- Q# 38. Alcohol or drug dependency
Are you? (check all that apply)
- Q# 39. Presently being treated for any other illness
- Q# 40. Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, diarrhea)
- Q# 41. A smoker, smoked previously, or use smokeless tobacco
- Q# 42. A consumer of alcoholic beverages
- Q# 43. FEMALE – Taking birth control pills
- Q# 44. FEMALE – Pregnant
- Q# 45. MALE – Prostate disorders
If you answered yes to any question above please provide some details:
Q# Medical condition Years since first onset Other
Describe any medical conditions that run in your family (parents, grandparents, etc.)
Medical condition (Family) Description
Describe any serious short-term, acute medical condition requiring hospital admission (e.g., meningitis, pneumonia):
Medical condition (Acute) Description Years since onset Duration in weeks
Describe any current medical treatment, impending surgery, or other invasive treatment (e.g., Botox, collagen injections)
Treatment Description
List all medications, supplements, and or vitamins taken within the last two years:*
Drug Dose Frequency Year started Purpose
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Medical condition (Acute)	Description	Years since onset	Duration in weeks

City	Country

Age	Your doctor's name	Your doctor's specialty

Treatment	Description

Drug	Dose	Frequency	Year started	Purpose