Fullscript Screen
Be Well Therapies Supplement Screen Form
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Email *
Patient Name *
Email *
Mobile Number
Please list supplements are you currently taking: (name, dose, frequency taking) *
Please list medications you are currently taking: (name, dose, frequency) *
Please list your medical history: (Please list pertinent medical history such as high cholesterol, high blood pressure, diabetes.) *
Are you looking for recommendations for specific supplements? If so please list and/or describe.
What are you (if anything) specifically interested in learning more about? Please list any other details you want to convey to the Be Well Therapies team, including educational topics.
By clicking on 'submit',  you understand that this is a SCREEN. This is not a substitute for medical advice. This form is not intended to help diagnose or treat a specific condition, but is instead used to gather appropriate recommendations and provide education on some supplements that have evidence-basis for suggesting use as well as provide education on lifestyle medicine pillars. Be Well Therapies advocates plant-predominant eating and gathering as many nutrients, vitamins, and minerals as possible from whole foods before taking a supplement. Be Well Therapies understands that even with the most ideal diet, there is a time and place for supplementing with additional products, such as vitamin D. Please consult with your physician or medical provider about specific use, side effects, and possible drug interactions before taking any supplement. This screening process provides recommendations, not a prescription.
Be Well Therapies Supplement Screen
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