NAD+ Patient Questionnaire

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NAD+ Patient Questionnaire

Please complete this brief questionnaire so our clinical team can review your health history and determine whether the NAD+ program may be appropriate for you. Your responses are reviewed as part of the intake process and help us ensure treatment is handled safely and appropriately.

1
What is your first and last name?* This field is required.
First Name
Last Name
2
Nice to meet you, {whatIs}! How physically active are you?* This field is required.
Sedentary
Somewhat Active
Active but not Athletic
Athletic
Competitive / Biohacker
3
How tall are you?* This field is required.Please use feet/inches.
4
How much do you weigh?* This field is required.Please use pounds.
5
What is your Date of Birth?* This field is required.This information is required in order to fill your prescription.
Date
Month
Day
Year
6
Do you have any one of the following Medical Conditions?* This field is required.
No Medical Problems/Conditions
Diabetes
Hypertension (high blood pressure)
Heart disease
Thyroid condition
Asthma or COPD
Anxiety or depression
HIV or AIDS
Kidney disease
Cancer
Irregular heart beat
Vascular disease (stroke, blood clots, etc)
Other
7
Have you ever been told your kidneys are not working properly?* This field is required.
YESNO
8
Have you ever been told your liver is not working properly?* This field is required.
YESNO
9
Have you ever been told your heart is not pumping properly?* This field is required.
YESNO
10
Do you currently smoke?* This field is required.
YESNO
11
Do any of your immediate family members have a history of the following conditions?* This field is required.
Cancer
Heart Disease
Dementia
Diabetes
High Blood Pressure
High Cholesterol
None of these
12
Have you had any of the following surgeries?* This field is required.
No past surgeries
Back or Neck surgery
Heart surgery or stenting
Prostate surgery (Men only)
Hysterectomy (Female only)
Gallbladder
Appendix
Other
13
Do you have a primary care provider?* This field is required.
YESNO
14
Have you had a general health check-up or routine physical in the past three years?* This field is required.
YESNO
15
Do you take any medication?* This field is required.
YESNO
16
Please list medications you take below* This field is required.
Huge
Large
Normal
Small
Ok
Ok
17
Do you have any allergies?* This field is required.
None
Penicillin/Amoxicillin
Sulfa Drugs
Aspirin
Codeine
Latex
Vitamin B/Niacin
Other
18
Prior to discovering NADforWellness.com, how important was the idea of longevity or slowing down aging to you?* This field is required.
No Importance/Didn't Care
Very Little Importance
Some Importance
Moderate Importance
Significant Importance
19
What's your email address?* This field is required.We ask for your email address so our medical provider can contact you with any questions about your treatment plan. We will not sell or share your information with any third party.
example@example.com
20
Do you currently live in California?* This field is required.Please be advised: we are currently not able to provide services outside of California.
YESNO
Should be Empty:

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