My Medications, Vitamins And Supplements - MyHealth Analysis™

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My Medications, Vitamins & Supplements

This form will allow your on-line doctor to determine if there could be possible side effects with any drugs you take and to assure that there are no adverse interactions with your supplement recommendations.

The information you enter in this form is completely confidential and is not shared with any other source, unless requested in writing.

My Medications, Vitamins And Supplements ( Required)

Medications

List All Medications (prescribed and over-the counter) you are CURRENTLY TAKING. If you do not take any prescription medications either prescribed or over-the-counter check this box and continue below. I do not take any medications

Medications I Take (prescribed and over-the counter)
Name of Medication	Amount Per Day	Reason Taking	How Long	Results	Side Effects Noticed
	mg.
	mg.
	mg.
	mg.
	mg.
	mg.
	mg.
	mg.
	mg.
	mg.

Vitamins, Minerals, Herbs & Other Supplements

Please list all vitamins, minerals, herbs, and other nutritional supplements you CURRENTLY TAKE .If you do not take any vitamins, minerals, herbs or other supplements, check this box and continue below. I do not take any vitamins, minerals, herbs or other supplements:

Vitamins, Minerals, Herbs & Other Supplements I Take
Name of Supplement	Name of Company	Amount Per Day	Reason Taking	How Long	Results
		mg or I.U.
		mg or I.U.
		mg.or I.U.
		mg or I.U.
		mg or I.U.
		mg or I.U.
		mg or I.U.
		mg or I.U.
		mg or I.U.
		mg or I.U.

Please review this form to be sure you have answered the appropriate items and that your answers are accurate. Thank you for choosing BecomeHealthyNow.com. We look forward to helping you achieve your your health goals.

Please Note:

You have already completed this sub-section of the MyHealth Analysis questionnaire. Your answers are recorded above for you to review. If any of the data in the form is NOT correct and you need to CHANGE your answers, click the appropriate button below. You will then be allowed to make any necessary changes.

Please Note This Section is Complete:

You have already completed this entire section of the MyHealth Analysis questionnaire. Your answers are recorded above for you to review. If any of the data in this subsection or any other subsection is NOT correct and you need to CHANGE your answers, call your on-line doctor, {doc_name} at {doc_phone}. He will make this entire section incomplete and you will be able to make changes to any sub-section. Your previous answers will NOT be lost, and you will be able to review each sub-section and make changes.

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