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Dr. Lori's "Rapid Rx" - Fast Prescription & Supplement Intake
Please take a few moments to complete this symptom review so that Dr. Lori Gerber can give you the prescriptions & supplement recommendations personalized for you! Please fill out the questions that apply to the product you are looking for. FOR: BASIC SUPPLEMENT RECOMMENDATIONS, LATISSE LASH LENGTHENING, BODY BOOST METABOLISM SHOTS, ACNE MEDICATIONS, UPNEEQ EYE LID LIFT!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Please Select
Male
Female
N/A
Birth Date
*
Please select a month
January
February
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June
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Please select a day
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Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supplement recommendation Symptom Review - Please rank your symptoms from 1 is not severe to 5 is severe.
Rows
1
2
3
4
5
N/A
Fatigue
Hot Flashes
Night Sweats
Diarrhea
Constipation
Food Sensitivities
Anxiety
Depression
Mood Swings
Headaches
Insomnia
Sensitivity Heat/Cold
Brittle Hair/Nails
Difficulty AM Wake Up
Weight Gain
Belly Fat
Insulin Resistance
Diabetes
Weight Loss
Joint Pains
Body Aches
Loss Taste/Smell
Exercise Intolerance
Blurred Vision
New Vision Disturbances
History of Autoimmune
Disease
Brain Fog
Low Libido
Difficulty / Change
in Orgasm
Lack of Morning Erections
Erectile Dysfunction
History of Irritable Bowel
Syndrome
History of Inflammatory Bowel
Disease
LATISSE - Lash Lengthener & Thickener -- Lash Symptom Review - Please answer Yes/No to questions below
*
Rows
Yes/No
Thinning Lashes
Yes
No
Short Lashes
Yes
No
Light Colored Lashes
Yes
No
Eyelid Stye History
Yes
No
Prescription Topical Acne Products - Acne Symptom Review - Please answer Yes/No and Severe/Mild if relevant to questions below:
*
Rows
Yes/No
Severe
Mild
Frequent Breakouts
Yes
No
Yes
No
Yes
No
Red, Inflamed Acne Bumps
Yes
No
Yes
No
Yes
No
Small, Closed, Acne Bumps
Yes
No
Yes
No
Yes
No
Blackheads
Yes
No
Yes
No
Yes
No
Oily Skin All Over
Yes
No
Yes
No
Yes
No
Dry Skin All Over
Yes
No
Yes
No
Yes
No
T-Zone Oily
Yes
No
Yes
No
Yes
No
Skin Type 1-2 - (lighter skin)
Yes
No
Yes
No
Yes
No
Skin Type 3-6 - (darker skin)
Yes
No
Yes
No
Yes
No
Sensitive Skin - Dries or Gets Red Easily
Yes
No
Yes
No
Yes
No
Please upload a photo of your skin - front of the face and profile.
Injectable VITAMIN BODY BOOSTS - Symptom Review - Please answer Yes/No and Severe/Mild if relevant to questions below:
*
Rows
Yes/No
Severe
Mild
Fatigue
Yes
No
Yes
No
Yes
No
Trouble with exercise recovery
Yes
No
Yes
No
Yes
No
Brain Fog
Yes
No
Yes
No
Yes
No
Poor exercise tolerance
Yes
No
Yes
No
Yes
No
Frequent colds or frequently exposed to illness
Yes
No
Yes
No
Yes
No
Thinning hair
Yes
No
Yes
No
Yes
No
Thinning nails
Yes
No
Yes
No
Yes
No
Skin Dullness
Yes
No
Yes
No
Yes
No
Skin Dryness
Yes
No
Yes
No
Yes
No
UPNEEQ - Eyelid Opener -- Symptoms of asymmetrical eyes, loss of elasticity of eye lids or small eyes, whites of the eyes yellowing or red.
*
Rows
Yes/No
Severe
Mild
One Eye Asymmetrical
Yes
No
Yes
No
Yes
No
Eyelids heavier with age
Yes
No
Yes
No
Yes
No
Small eyes genetically
Yes
No
Yes
No
Yes
No
Partial Facial Paralysis (eye palsy)
Yes
No
Yes
No
Yes
No
Red or Yellowing Whites of Eyes
Yes
No
Yes
No
Yes
No
Eye sensitivity / Irritate easily
Yes
No
Yes
No
Yes
No
History of Narrow-Angle Glaucoma (self)
Yes
No
Yes
No
Yes
No
History of Sjogren's Syndrome (Autoimmune Dry Eye)
Yes
No
Yes
No
Yes
No
Cardiovascular Disease
Yes
No
Yes
No
Yes
No
Orthostatic Hypotension (low blood pressure with standing)
Yes
No
Yes
No
Yes
No
Uncontrolled High Blood Pressure
Yes
No
Yes
No
Yes
No
Uncontrolled Low Blood Pressure
Yes
No
Yes
No
Yes
No
Please upload a photo of your eyes - front
Please provide any details or history of need for any of the medications above?
*
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