Mint Med Energy Eligibility Quiz

Mint Med Energy Eligibility Quiz

Answer a few quick questions to help us determine if you’re eligible for treatment.Your information is confidential and will be reviewed by a licensed medical provider.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Symptoms & Indications(patients please check all that apply)

Fatigue / low energyBrain fog / poor concentrationLow moodDifficulty losing weightSleep issuesHair/nail weaknessExercise recovery difficultyChronic stress/burnoutOther
Do you have any allergies? Please list below or type N/A

Do you have a history of liver disease, kidney disease, or heart conditions? If yes, please list below. If no, please type N/A
Please describe below
Do you have a history of cancer or current malignancy?
Please describe below

Do you have a history of seizures or neurological disorders? If yes, please explain. If no, please type N/A

History of heart disease, arrhythmia, or uncontrolled blood pressure?
Please type yes or no. If yes, include most recent high reading.
Frequent chest pain, palpitations, or shortness of breath?
Please describe above.

Pregnancy and Breastfeeding precaution
The FDA says that these medications may pose a risk to the developing fetus (baby) if you get pregnant while taking it. “The pill” (oral contraception) is not enough because this medication can interfere with the effectiveness. For effective birth control our doctors recommend to use condoms, an IUD, or the implant. Official FDA recommendations: For the first month after first starting a weight loss medication, and for the first month after each dose escalation, continue using your oral contraception and talk with your doctor about any additional measures that may be recommended to prevent pregnancy. Alternatively, you can switch to a non-oral contraceptive method (such as an IUD or implant) before starting your medication. When you stop the medication, you must continue using a backup method (like condoms) for two months after stopping to allow the medication to fully leave your system before getting pregnant. Similarly, it is not known to be safe in breastfeeding. If you are breastfeeding, consult your doctor for safe weight loss options.
By checking this box, you acknowledge the above information

Are you taking: Blood pressure medication, Metformin, chemotherapy drugs, anticonvulsants, Other vitamins/injections (please list)
Please describe in box above