- CosmeticRX

Next, let’s go through your health history.

Do you have any one of the following Medical Conditions? (Check all that apply)

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

Please describe more about your Diabetes

Please describe more about your Hypertension

Please describe more about your Heart Disease

Please describe more about your Thyroid Condition

Please describe more about your Asthma or COPD

Please describe more about your Anxiety or Depression

Please describe more about your HIV or AIDS

Please describe more about your Kidney Disease

Please describe more about your Cancer

Please describe more about your Irregular Heart Beat

Please describe more about your Vascular Disease

Please describe more about your Other

Have you ever been told your kidneys are not working properly?

Yes No

Please describe more about your Kidneys not working properly

Have you ever been told your liver is not working properly?

Yes No

Please describe more about your Liver not working properly

Have you ever been told your heart is not pumping properly?

Yes No

Please describe more about your Heart not working properly

Have you had any of the following surgeries? (Check all that apply)

No past surgeries Back or Neck surgery Heart surgery or stending Prostate surgery (Men only) Hysterectomy (Female only) Gallbladder Appendix Other

Have you had a general health check-up or routine physical in the past three years

Yes No

Please describe more about your Physical routine

Please list all medications you are currently taking or using

Include any prescription and over-the-counter medications, supplements, implants, or patches

Please list all allergies you have

Almost done! Next, we have a few medication-specific questions.

What is your primary reason for requesting Trazodone?

I have trouble falling asleep I have trouble staying asleep I suffer from poor sleep quality Other

Have you ever taken Trazodone before?

Yes No

Have you ever taken any of the following prescriptions as treatment for sleep issues? (Select all that apply)

Doxepin Ambien Lunesta A benzodiazepine (Temazepam, Alprazolam, Clonazepam, etc.) A mood stabilizer (Seroquel or Remeron) Other None of the above

Have you ever taken any of the following no-prescriptions as treatment for sleep issues? (Select all that apply)

Melatonin Cannabis Other herbal products (Chamomile, Lavender, etc.) Behavioral therapy Other None of the above

Do you currently take any medication for sleep or mood, or medications that are commonly used for sleep or mood?

Yes No

Please describe more about your Currently taking medication

Are you currently on or do you plan to take any of the following medications?

Isocarboxazid Linezolid Methylene Blue by Injection Pimozide Plenelzine Safinamide Saquinavir Selegiline Transdermal Thioridazine Tranylcypromine I have not taken any of these, nor do I plan to

How long does it typically take for you to fall asleep?

It takes me less than 30 minutes to fall asleep It takes me 30 to 60 minutes to fall asleep It takes me more than 60 to 120 minutes to fall asleep It takes me more than 120 minutes to fall asleep

Do you have any of the following concerns about staying asleep?

I don't have any concerns about staying asleep I wake up at very specific times of the night, and have a hard time going back to sleep I wake up randomly during the night and have a hard time going back to sleep I wake up too early and can’t get back to sleep

Do you have any concerns about the quality of your sleep? (Select all that apply)

I do not have any concerns about sleep quality I snore excessively I wake up gasping for air My REM sleep is too low My Deep-wave sleep is too low Other

Do you have any concerns about day-time sleepiness? (Select all that apply)

No concerns Yes, because I get too little sleep Yes, even though I spend enought time in bed, but I am still sleepy Other

When do you typically go to sleep, and when do you wake up? (example: sleep by 10pm, awake by 6am)

On average, how many total hours of sleep are you getting at night?

Less than 5 hours Between 5-6 hours Between 6-7 hours Between 7-8 hours Between 8-9 hours More than 9 hours

When was the last time you had a restful night sleep?

Within the last week More than a week ago, but less than a month ago More than a month ago, but less than 3 months ago Between 3 and 6 months ago Over 6 months ago I don’t remember the last time I had a restful night sleep

How many nights per week do you have trouble with your sleep?

Less than once a week Once or twice a week Three or four times a week Five or six times per week Every night

What tests have you undergone to see why you might have sleep issues?

Blood test (to rule out thyroid or blood sugar issues) Sleep study (in a clinic) Sleep study (at home) Psychological Evaluation EEG (Electroencephalogram) None

Have you ever been diagnosed with any forms of bipolar disorder, or has it ever been suggested to you that you might have bipolar disorder?

Yes No

Please describe more about your Bipolar disorder

Have you ever experienced any of the following? (Select all that apply )

Hyponatremia (low blood sodium) or problems with volume depletion or electrolyte abnormalities Trouble with long QT syndrome or QT prolongation Trouble with heart arrhytmias such as Torsades de Pointes or Bradycardia Glaucoma or pressure issues in the eyes History or risk of priapism Any kind of seizures or elevated risk of seizures None of the above

What do you think causes the issues with your sleep? (Select all that apply)

Aging/Getting older Stress Medications Work Schedule Other

Is the anything else you want your prescriber to know about your condition or health?

Yes No

Please describe more

Which of the following apply to your reproductive status?

I am not currently pregnant or breastfeeding I am currently pregnant or breastfeeding I plan to become pregnant within the next 6 mounths I am currently going through menopause I had a hysterectomy or am post-menopausal I am a male (N/A)

All set. Thanks

You are not alone. Those with comparable symptoms often benefit from medication. We will now have one of the Board-Certified psychiatrists at CosmeticRx.com review your consultation.

CosmeticRx has the guaranteed lowest price of any US telehealth company for a 3 month (90 days) supply of .

Do you have any one of the following Medical Conditions? (Check all that apply)

Have you ever been told your kidneys are not working properly?

Have you ever been told your liver is not working properly?

Have you ever been told your heart is not pumping properly?

Have you had any of the following surgeries? (Check all that apply)

Have you had a general health check-up or routine physical in the past three years

Please list all medications you are currently taking or using

Please list all allergies you have

What is your primary reason for requesting Trazodone?

Have you ever taken Trazodone before?

Have you ever taken any of the following prescriptions as treatment for sleep issues? (Select all that apply)

Have you ever taken any of the following no-prescriptions as treatment for sleep issues? (Select all that apply)

Do you currently take any medication for sleep or mood, or medications that are commonly used for sleep or mood?

Are you currently on or do you plan to take any of the following medications?

How long does it typically take for you to fall asleep?

Do you have any of the following concerns about staying asleep?

Do you have any concerns about the quality of your sleep? (Select all that apply)

Do you have any concerns about day-time sleepiness? (Select all that apply)

When do you typically go to sleep, and when do you wake up? (example: sleep by 10pm, awake by 6am)

On average, how many total hours of sleep are you getting at night?

When was the last time you had a restful night sleep?

How many nights per week do you have trouble with your sleep?

What tests have you undergone to see why you might have sleep issues?

Have you ever been diagnosed with any forms of bipolar disorder, or has it ever been suggested to you that you might have bipolar disorder?

Have you ever experienced any of the following? (Select all that apply )

What do you think causes the issues with your sleep? (Select all that apply)

Is the anything else you want your prescriber to know about your condition or health?

Which of the following apply to your reproductive status?

All set. Thanks

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