Performance Anxiety

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7
Please click all that apply to your current situation* This field is required.
Avoid social situations
Fear of judgement in social settings
Almost always have fear when it comes to social settings
Anxiety during car or plane rides
Fear before public speaking, presentations, interviews, dates
Fear, anxiety or avoidance >6 months
Sweating, rapid heart rate or shakiness when you experience anxiety
Fear out of proportion to your actual experience
None of the above
8
Please describe the problems you are experiencing and what has been bothering you the most
9
Do you have any of the following conditions? Check all that apply* This field is required.
Peripheral Vascular Disease
Pregnancy
Liver Disease
Kidney Disease
HTN
Glaucoma
Erectile Dysfunction
Bipolar Disorder
Schizophrenia
Parkinsons
Asthma/COPD
Heart Arrhythmias
History of Heart Attack
Slow Heart Rate
Insulin use for diabetes
Light headed after standing
History of gastric Bypass
None of the above
10
What was your most recent (within the last 6 months) blood pressure reading? Please provide the Systolic blood pressure value (the top number)* This field is required.It is important for this to be accurate as the medications to treat anxiety can cause serious harm and/or death if taken improperly. If you do not know your most recent blood pressure do not proceed until one is obtained.
Below 90 (low)
90-109 (lower)
110-140 (normal)
141-160 (high)
Above 160 (very high)
11
Please provide your Diastolic Blood pressure value (the bottom number)* This field is required.
Less than 60 (low)
60-69 (lower)
70-85 (normal)
86-95 (high)
Greater than 95 (very high)
12
Do you have any known allergies to foods or medications?* This field is required.
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Please list all allergies
14
What Medications do you Currently Take?* This field is required.Include all prescription medications or herbal supplements. If you take no medications then type "none"
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Performance Anxiety Products* This field is required.
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ORDER SUMMARY
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SubtotalUSD
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Propranolol10mg 30ct
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Propranolol10mg 60ct
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Propranolol20mg 30ct.
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Propranolol20mg 60ct
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
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Bhutan
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Botswana
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
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Saint Barthelemy
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Samoa
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Saudi Arabia
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Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
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Sudan
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Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
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Tanzania
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Timor-Leste
Togo
Tokelau
Tonga
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Ukraine
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