Low Dose Naltrexone
As you know, you will start low and slowly titrate up on your LDN RX as directed by your prescription. We strongly encourage you to complete this form ONCE PER WEEK for two reasons. 1) It'll be easier for you to determine your optimal dose, and 2) memory fades but your symptom journal dose not.
Today's Date
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Month
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Day
Year
Date
Patient Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Gender
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Please Select
Male
Female
E-Mail
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example@example.com
Phone Number
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Please enter a valid phone number.
Are you currently taking LDN?
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Please Select
Not started
Yes
Stopped
Please let us know when you last tried LDN, how long did you take it for, what the dose titration schedule was and the reason why you stopped?
Please select what category of condition you are taking LDN for.
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Cardiac (Heart) Diseases
Chronic Pain
Dermatologic (Skin) Diseases
Ear, Nose, Sinus, Throat
Endocrine Diseases
Gastrointestional Diseases
Hematologic/Blood Marrow Disorders
Hetatology (Liver Conditions)
Immunology
Infectious Diseases
Malignancies/Cancer
Neurologic Diseases
Ocular (Eye Disease)
Pediatric Disorders
Psychological Disorders
Pulmonary (Lung) Diseases
Renal (Kidney) and Urologic Diseases
Rheumatologic (Arthritis and Autoimmune) Disorders
Sleep Disorders
Vasculitis
Women's Health
Other
Please specify which Cardiac (heart) Condition(s):
Autoimmune cardiomyopathy
Autoimmune myocarditis
Autoimmune thrombocytopenic purpura
Congenital heart block
Coxsackie myocarditis
Dressler's syndrome (postmyocardial infarction syndrome)
Giant cell myocarditis
Kawasaki disease
Polyarteritis nodosa
Postpericardiotomy syndrome
Subacute bacterial endocarditis (SBE)
Vasculitis
Other
Please specify which Chronic Pain Condition(s):
Complex Regional Pain Syndrome/RSD
Diabetic Neuropathy
Migraines
Peripheral neuropathy
Temporomandibular joint disorder
Other
Please specify which Dermatologic (Skin) Condition(s):
Alopecia areata
Alopecia universalis
Amyopathic Dermatomyositis
Anti-synthetase syndrome
Atopic allergy
Atopic dermatitis
Autoimmune progesterone dermatitis
Autoimmune urticaria
Bechet’s syndrome
Benign mucosal pemphigoid
Blau syndrome
Bullous pemphigoid
Cicatricial pemphigoid
Cutaneous leukocytoclastic angiitis
Darier Disease
Dego's disease (thrombotic vasculopathy)
Dercum's disease (adiposis dolorosa)
Dermatitis herpetiformis
Dermatomyositis
Diffuse cutaneous systemic sclerosis
Discoid lupus erythematosus
Eczema
Epidermolysis bullosa acquisita
Erythema nodosum
Erythmodermic psoriasis
Essential mixed cryoglobulinemia
Familial cold autoinflammatory syndrome (FCAS)
Frontal Fibrosing Alopecia (FFA)
Hailey-Hailey Disease
Herpes gestationis/pemphigoid gestationis (PG)
Hidradenitis Suppurativa (HS) (Acne Inversa)
Kawasaki disease
Lichen planus
Lichen sclerosus
Linear IgA disease (LAD)
Majeed syndrome
Morphea Mucha-Habermann disease, PLEVA (pityriasis lichenoides et varioliformisacuta)
Myositis
Neonatal lupus
Parry Romberg syndrome
Pemphigus vulgaris
POEMS syndrome
Progesterone dermatitis
Psoriasis
Pyoderma gangrenosum
Schnitzler syndrome
Schulman disease
Subacute cutaneous lupus erythematosus (SCLE)
Sweet's syndrome
Topical Steroid Withdrawal (TSW)
Vitiligo
Vogt-Koyanagi-Harada Disease
Other
Please specify which Ear / Nose / Sinus / Throat Condition(s):
Autoimmune inner ear disease (AIED)
Burning mouth syndrome
Churg-Strauss syndrome
Cogan syndrome
Ménière's disease
Susac's syndrome
Other
Please specify which Endocrine Condition(s):
Addison's disease
Autoimmune polyendocrine syndrome
Cushing's syndrome
Diabetes mellitus type 1
Eosinophilic esophagitis (EoE)
Glycogen storage disorder (GSD VII)
Graves' disease
Hashimoto's thyroiditis
Hypoglycaemia
Hypopituitary or Secondary adrenal insufficiency
Hypothalamic Dysfunction
Hypothyroidism
Juvenile diabetes (Type 1 diabetes)
Ord’s thyroiditis
Pituitary dysfunction
POEMS syndrome
Polyglandular syndromes type I, II, III
Schmidt syndrome
Thyroid eye disease (TED)
Thyroiditis
Other
Please specify which Gastrointestinal Condition(s):
Autoimmune hepatitis
Autoimmune enteropathy
Autoimmune pancreatitis
Celiac disease
Churg-Strauss syndrome
Crohn’s disease
Eosinophilic gastroenteritis
Gastritis
Gastrointestinal pemphigoid
Gastroparesis
Gluten sensitivity
Gut dysbiosis
Inflammatory bowel disease (IBD)
Irritable bowel syndrome (IBS)
Lupoid hepatitis
Nonalcoholic steatohepatitis (NASH)
Mesenteric Panniculitis
POEMS syndrome
Polyarteritis nodosa
Primary biliary cirrhosis
Primary sclerosing cholangitis
Pyoderma gangrenosum
Small intestinal bacterial overgrowth (SIBO)
Schnitzler syndrome
Ulcerative colitis (UC)
Other
Please specify which Hematologic / Blood Marrow Condition(s):
Agammaglobulinemia
Antiphospholipid syndrome
Autoimmune aplastic anemia
Autoimmune hemolytic anemia
Autoimmune lymphoproliferative syndrome
Castleman's disease (CD) – lymph node hyperplasia
Cold agglutinin disease
Evans syndrome
Hemolytic anemia
Henoch-Schonlein purpura (HSP)
Immune thrombocytopenic purpura (ITP)
Kawasaki disease
Majeed syndrome
Microscopic polyangiitis
Monoclonal gammopathy of undetermined significance (MGUS)
Myelodysplastic syndromes
Neutropenia
Paroxysmal nocturnal hemoglobinuria (PNH)
Pernicious anemia (PA)
POEMS syndrome
Pure red cell aplasia (PRCA)
Raynaud’s phenomenon
Thrombocytopenic purpura (TTP)
Other
Please specify which Hepatology (Liver) Condition(s):
Hepatitis C
Primary Biliary Cholangitis
Other
Please specify which Immunologic Condition(s):
Amyloidosis
Autoimmune angioedema
Common Variable Immunodeficiency
Epstein Barr Virus
IgG4-related sclerosing disease
Juvenile myositis (JM)
Mast cell activation syndrome (MCAS)
Mold toxicity
Pernicious anemia (PA)
Vitiligo
Other
Please specify which Infectious Disease Condition(s):
Chagas disease
Complement component 2 deficiency – increase risk of infections
COVID
Coxsackie myocarditis
Herpes
Herpes Zoster (Shingles)
HIV/AIDS
Hypogammaglobulinemia – leads to infections
Long COVID
Lyme Disease
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections)
Sydenham chorea
Other
Please specify which Malignancy / Cancer Condition(s):
Adenoid Cystic Carcinoma
Bladder Cancer
Breast Cancer
Carcinoid Colon & Rectal Cancer
Cholangiocarcinoma
Colon Cancer
Esophageal carcinoma
Glioblastoma
Glioma
Hepatoblastoma
Leukemia
Liver cancer
Lung cancer (Non-small cell)
Lymphocytic leukemia (chronic)
Lymphoma (Hodgkin's and Non-Hodgkin's)
Malignant melanoma
Mesothelioma
Multiple myeloma
Neuroblastoma
Ovarian cancer
Pancreatic cancer
Parotid carcinoma
Prostate cancer (untreated)
Renal cell carcinoma
Throat cancer
Uterine cancer
Other
Please specify which Neurologic Condition(s):
Achalasia
Acute disseminated encephalomyelitis
Acute hemorrhagic leukoencephalitis
Alzheimer's
Amyotrophic Lateral Sclerosis (ALS)
Anti-mag IgM peripheral neuropathy
Arachnoiditis
Autism
Autoimmune dysautonomia
Autoimmune encephalomyelitis
Autoimmune peripheral neuropathy
Axonal & neuronal neuropathy (AMAN)
Baló disease/Baló concentric sclerosis
Bickerstaff's encephalitis
Brain fog
Charcot-Marie-Tooth syndrome
Chronic inflammatory demyelinating polyneuropathy (CIDP)
Crackly brain middle ear myoclonus (MEM)
Cranial arteritis
Devic’s disease (neuromyelitis optica)
Duchesne Muscular Dystrophy
Dystonia
Electromagnetic hypersensitivity
Guillain-Barré syndrome
Hashimoto's encephalitis
Idiopathic inflammatory demyelinating diseases
Inflammatory demyelinating polyneuopathy
Lambert-Eaton myasthenic syndrome
Leaky brain
Migraines
Miller-Fisher syndrome
Movement disorders
Multifocal Motor Neuropathy (MMN) or MMNCB
Multiple sclerosis (MS)
Myalgic encephalomyelitis
Myasthenia gravis
Myelin Oligodendrocyte Glycoprotein Antibody Disorder (MOG-AD)
Myositis
Narcolepsy
Neuromyelitis optica
Neuromyotonia
Neuropathy
Opsoclonus myoclonus syndrome
Optic neuritis
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections)
Paraneoplastic cerebellar degeneration (PCD)
Parkinson’s disease
Parry Romberg syndrome
Parsonage-Turner syndrome
Peripheral neuropathy
Perivenous encephalomyelitis
POEMS syndrome
Postural orthostatic tachycardia syndrome (POTS)
Progressive inflammatory neuropathy
Rasmussen's encephalitis
Restless legs syndrome (RLS)
Stiff person syndrome (SPS)
Susac's syndrome
Sydenham chorea
Tired brain syndrome
Tolosa-Hunt syndrome
Tourette syndrome
Transverse myelitis
Traumatic brain injury (TBI)
Trigeminal neuralgia
Vogt-Koyanagi-Harada Disease
Other
Please specify which Ocular (Eye) Condition(s):
Autoimmune retinopathy
Autoimmune uveitis
Blau syndrome
Cogan's syndrome
Devic’s disease (neuromyelitis optica)
Ligneous conjunctivitis
Miller-Fisher syndrome
Mooren’s ulcer
Neuromyelitis optica
Ocular cicatricial pemphigoid
Optic neuritis
Opsoclonus myoclonus syndrome
Pars planitis (peripheral uveitis)
Scleritis
Susac's syndrome
Sympathetic ophthalmia (SO)
Thyroid eye disease (TED)
Tolosa-Hunt syndrome (THS)
Uveitis
Vogt-Koyanagi-Harada Disease
Other
Please specify which Pediatric Condition(s):
Addison’s disease
Autism
Celiac disease
Congenital heart block
Crohn’s disease
Juvenile arthritis
Juvenile dermatomyositis
Juvenile diabetes (Type 1 diabetes)
Juvenile idiopathic rheumatoid arthritis
Juvenile myositis (JM)
Lupus
Multiple sclerosis (MS)
Neonatal Lupus
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections
Scleroderma
Type 1 diabetes
Ulcerative colitis (UC)
Other
Please specify which Psychological Condition(s):
Alcohol use disorder
Anxiety
Autism
Depersonalization/Derealization Disorder
Depression
Dissociative Disorder
Dissociative identity disorder
General Anxiety Disorder (GAD)
Hypervigilance
Obsessive Compulsive Disorder (OCD)
Opioid withdrawal
Panic Disorder
Phobias
Post-Traumatic Stress Disorder (PTSD)
Postpartum Depression
Premenstrual Dysphoric Disorder (PMDD)
Social Phobia
Stress
Substance abuse disorders
Trichotillomania
Other
Please specify which Pulmonary (Lung) Condition(s):
Anti-synthetase syndrome
Asthma Churg-Strauss syndrome
Emphysema
Fibrosing alveolitis
Granulomatosis with Polyangiitis (formerly Wegener’s Granulomatosis)
Goodpasture's syndrome
Idiopathic pulmonary fibrosis
POEMS syndrome
Sarcoidosis
Other
Please specify which Renal (Kidney) and/or Urologic Condition(s):
Anti-GBM/Anti-TBM Nephritis
Autoimmune orchitis
Autoimmune renal neuropathy
Berger's disease - IgA nephropathy
Glomerulonephritis
Goodpasture's syndrome
IgA nephropathy
Interstitial cystitis (IC)
Microscopic polyangiitis (MPA)
POEMS syndrome
Sperm & testicular autoimmunity
Other
Please specify which Rheumatologic (Arthritis and Autoimmune) Condition(s):
Adult Still's disease
Ankylosing spondylitis
Anti-synthetase syndrome
Arthritis
Chronic fatigue syndrome (CFS)
Chronic recurrent multifocal osteomyelitis (CRMO)
Complement component 2 deficiency – increase risk of lupus
CREST syndrome
Ehlers-Danlos Syndrome (EDS)
Enthesitis-related arthritis
Eosinophilic fasciitis
Fibrodysplasia ossificans progressive
Fibromyalgia
Inclusion body myositis (IBM)
Juvenile arthritis
Juvenile idiopathic arthritis
Juvenile rheumatoid arthritis – Still’s disease
Lupus erythematosus
Majeed syndrome
Mixed connective tissue disease (MCTD)
Morphea myositis
Myalgic Encephalopathy (ME)
Palindromic rheumatism (PR)
Polymyalgia rheumatica
Polymyositis
Psoriatic arthritis
Reactive Arthritis
Reiter's syndrome
Relapsing polychondritis
Retroperitoneal fibrosis
Rheumatic fever
Rheumatoid arthritis
Sarcoidosis
Schnitzler syndrome
Scleroderma
Seropositive arthritis
Sjögren's syndrome
Spondylitis
Spondyloarthropathy
Undifferentiated connective tissue disease (UCTD)
Undifferentiated spondyloarthropathy
Other
Please describe your sleep condition:
Please specify which vasculitis condition(s):
Blau syndrome
Behcet's disease
Churg-Strauss Syndrome (CSS) or Eosinophilic Granulomatosis (EGPA)
Essential mixed cryoglobulinemia
Giant cell arteritis (temporal arteritis)
Kawasaki disease
Leukocytoclastic vasculitis
Polyarteritis nodosa
Takayasu's arteritis
Temporal arteritis/Giant cell arteritis
Other
Please specify which Women's Health Condition(s):
Autoimmune oophoritis
Endometriosis
Healthy pregnancy – new concepts
Herpes gestationis/pemphigoid gestationis (PG)
Infertility
PMS (premenstrual syndrome)
Polycystic Ovary Syndrome (PCOS)
Pregnancy
Premenstrual syndrome (PMS)
Progesterone dermatitis
Recurrent vaginitis
Reduced ovarian reserve (Low AMH)
Vaginitis
Vulvodynia
Painful periods (Dysmenorrhea)
Other
Please rate your current symptoms. 5 being severe, occuring almost daily 1 being mild or rarely occuring
No Symptoms
1
2
3
4
5
Anxiety
Agitation
Depression
Fatigue
Poor Memory
Headache
Nausea
Loose Stool
Heart Burn / GI Discomfort
Swelling
Vivid Dreams
Pain
Neuropathic / Nerve Pain
Aches
Eczema / Psoriasis
Rash
Dry Skin
Dry Hair
Acne
Brain Fog
Dizziness
Weight Loss
Irregular Periods
PMS Symptoms
Difficulty Staying Asleep
Difficulty Falling Asleep
Insomnia
Do you take supplements?
Yes
No
Select which supplements you take:
Glucosamine
Turmeric
CBD
Vitamin D
Omega-3 / Fish Oil
Cod Liver Oil
Collagen
Vitamin C
Coenzymes Q10 (CoQ10)
Multi-Vitamin
Probiotic
Magnesium
Herbal supplements
Zinc
Other
What dose of LDN are you currently taking?
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Please Select
None
0.5 mg
1 mg
0.5 mg
2 mg
0.5 mg
3 mg
0.5 mg
4 mg
0.5 mg
5 mg
0.5 mg
6 mg
Other
Please treat this like a journal entry. Summarize how you have been feeling since your last check in. Any changes, good or bad? Can you do things now that you couldn't before?
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