VITAMIN B12 PRESCRIPTION REQUEST FORM Step 1 of 4 – Your Details 25% YOUR DETAILS(Required) Title (Mr/Mrs/Ms) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name DOB(Required) MM slash DD slash YYYY Phone(Required)Email(Required) YOUR HOME ADDRESS(Required) Street Address City ZIP / Postal Code GP SURGERY FULL ADDRESS Street Address City ZIP / Postal Code MEDICATIONSPlease list down any medications you are currently takingCONTRA-INDICATIONSPlease select any contra-indications for im Hydroxocobalamin B12 injection that apply to you NONE COBALT ALLERGY COBALAMIN AND DERIVATIVE ALLERGIES LOW BLOOD POTASSIUM LEVELS LEBER’S HEREDITARY OPTIC ATROPHY PREGNANT UNDER 18 UNDERGOING CANCER TREATMENT INDICATIONSIf you have no symptoms listed below – please select ‘other’ at the bottom to add any other symptoms, concerns that you have and reasons for requesting treatment (such as lack of energy/trouble sleeping etc)Please select any indications for IM Hydroxocobalamin B12 injection that may apply to you. ABNORMALLY PALE FACIAL COMPLEXION ACID REFLUX THAT OCCURS REGARDLESS OF DIET AGGRESSIVE BEHAVIOUR THAT IS NEW OR UNUSUAL ALTERED PALATE, FOOD TASTES DIFFERENT ALWAYS FEELING COLD ANXIETY BAD BREATH, HALITOSIS BLURRING OR DOUBLE VISION BLURRING OR DOUBLE VISION BRUISE EASILY BURSITIS CELIAC DISEASE CHRONIC DAILY FATIGUE CHRONIC PANCREATITIS CONFUSION, MUDDLED THINKING, BRAIN FOG CONSTANTLY ITCHY SKIN CONSTIPATION CONTINUOUS MOUTH ULCERS CRACKED SORES AT BOTH CORNERS OF YOUR MOUTH CROHN’S DISEASE DEPRESSION THAT LASTS WITHOUT APPARENT CAUSE DIFFICULTY BUILDING MUSCLE MASS DIFFICULTY SWALLOWING DIZZINESS, UNSTEADINESS, POOR STABILITY DRY MOUTH, UNPLEASANT TASTE IN MOUTH EARLY ONSET MENOPAUSE EASILY DISTRACTED ECZEMA, DRY SKIN RASHES ERECTILE DYSFUNCTION ESOPHAGEAL ULCERS EVERYDAY DIARRHEA FIBROMYALGIA FLATULENCE FREQUENT CLUMSINESS FREQUENT HEARTBURN, DESPITE EATING HEALTHY FREQUENT MISCARRIAGES, SPONTANEOUS ABORTIONS FREQUENT STOMACH BLOATING FREQUENT STOMACHACHES GASTRIC BYPASS SURGERY HAIR LOSS NOT RELATED TO AGE HALLUCINATIONS, DELIRIUMS HEART PALPITATIONS THROUGHOUT DAY HORMONAL IMBALANCES HYPERACUSIS HYPERHOMOCYSTEINEMIA HYPERSENSITIVITY HYPOTHYROID OR HYPERTHYROID DISORDER INFERTILITY INSOMNIA OR SPORADIC SLEEP INTESTINAL BACTERIAL OVERGROWTH INTESTINAL BACTERIAL OVERGROWTH IRRITABILITY JOINT PAIN LANGUAGE IMPAIRMENTS IN CHILD LOSING YOUR BREATH EASILY LOSS OF APPETITE LOW SPERM COUNT MEMORY IMPAIRMENTS MOOD SWINGS MUSCLE FATIGUE OR STIFFNESS NAUSEA NECK PAIN NEUROSIS, FIXATIONS NIGHT TERRORS OCCASIONAL VERTIGO OR ROOM SPINNING OPTIC NEURITIS PERIPHERAL NEUROPATHY PERNICIOUS ANEMIA PERSISTENT HEADACHES PINS AND NEEDLES PMS POOR CONCENTRATION, ADD- LIKE SYMPTOMS POOR CONTROL OF LIMB MOVEMENTS POOR DEVELOPMENT IN NEWBORN BABY POOR OR SLOW NERVE REFLEXES POST-PARTUM DEPRESSION PREMATURE GREY HAIR RECURRENT PANIC ATTACKS RED TONGUE THAT IS ABNORMALLY SMOOTH REDUCED LIBIDO SORE TONGUE, BURNING MOUTH SENSATION STRANGE THIRST, CONSTANTLY DEHYDRATED STRICT VEGETARIAN THIN, RIDGED NAILS THAT BREAK EASILY TINNITUS UNUSUAL METALLIC TASTE IN MOUTH UNUSUAL WEIGHT LOSS OR WEIGHT GAIN VEGAN WEAK PULSE YEAST INFECTIONS THAT OCCUR OFTEN OTHER / REASON FOR REQUESTING TREATMENT As you selected "OTHER", please include details here VERIFICATIONCOVID – 2 Weeks Clear Of Vaccination?Select An OptionYESNOConsent(Required) I agree that all the information I have provided above is correct.Print Name(Required) First Date(Required) Signature(Required)
