Nation Rx Advocates, LLC.

Patient Details

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Date Of Birth (mm/dd/yyyy)*

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Add Secondary Insurance

Policy Holder

First Name (if not Self)

Last Name (if not Self)

DOB (if not Self) *

Insurance Name

Insurance Type

Member ID

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Account Verification

Answer the following questions:

Do you take multiple medications?

Do you have any heart-related conditions?

Do you have, or have you had cancer?

Do you have diabetes?

Do you experience leg pain?

Are your legs swollen, painful, red, or warm to the touch?

Have you been diagnosed with Parkinson’s disease, Alzheimer’s Disease, Huntington’s Disease, or Dementia?

Have you ever been diagnosed with congestive heart failure, chronic bronchitis, pulmonary emphysema, or COPD?

Are you interested in testing for Covid-19?

Are you interested in testing for Covid/Flu?

Are you interested in continuous glucose monitoring?

Are you interested in Peanut Allergy testing?

Is the individual on Omalizumab (Xolair)?

Is the individual on immunotherapy for foods?

Is the individual being treated for multiple myeloma?

Confirm the test(s) you'd like to proceed with:

CGX

Is there a history of cancer in your family? (Family History)

Relationship

Family Side

Age at diagnosis

Cancer Site(s)

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Personal Cancer History

Please answer YES/NO to the following personal history questions.

Bladder Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Brain Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Breast Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Was the Breast Cancer/Tumor Bilateral?

Was the Breast Cancer/Tumor Premenopausal?

Was the Breast Cancer/Tumor Triple Negative?

Was the Breast Cancer/Tumor Multiple Primaries?

Cervical

Age at Diagnosis

Are you currently in treatment for this cancer?

Colon/Rectal Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Have you ever had a colonoscopy?

When was your last colonoscopy?

Did they find anything abnormal from the colonoscopy?

Did colonoscopy find polyps?

Number of polyps found?

Did they do a biopsy after colonoscopy?

Any other tumor(s) that where benign?

Endocrine Cancer? (Adrenal, Neuroendocrine, Parathyroid, Pituitary, Thyroid)

Age at Diagnosis

Are you currently in treatment for this cancer?

Endometrial

Age at Diagnosis

Are you currently in treatment for this cancer?

Esophagus

Age at Diagnosis

Are you currently in treatment for this cancer?

Fallopian Tube Cancer

Age at Diagnosis

Are you currently in treatment for this cancer?

Hematologic Cancer/Leukemia?

Age at Diagnosis

Are you currently in treatment for this cancer?

Intestine

Age at Diagnosis

Are you currently in treatment for this cancer?

Kidney Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Liver Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Lung Cancer?

Age at Diagnosis

Are you currently in treatment for this cancer?

Lymphoma Cancer

Age at Diagnosis

Are you currently in treatment for this cancer?

Lynch Syndrome

Age at Diagnosis

Are you currently in treatment for this cancer?

Melanoma Cancer

Age at Diagnosis

Are you currently in treatment for this cancer?

Ovarian

Age at Diagnosis

Are you currently in treatment for this cancer?

Pancreatic Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Respitory organs (sinuses, nasal cavities)

Age at Diagnosis

Are you currently in treatment for this cancer?

Sarcoma Cancer

Age at Diagnosis

Are you currently in treatment for this cancer?

Small Intestine

Age at Diagnosis

Are you currently in treatment for this cancer?

Stomach Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Testis

Age at Diagnosis

Are you currently in treatment for this cancer?

Trachea/Broncheus/Lung

Age at Diagnosis

Are you currently in treatment for this cancer?

Uterine

Age at Diagnosis

Are you currently in treatment for this cancer?

Other Cancer/Tumor?

Age at Diagnosis

Are you currently in treatment for this cancer?

Other Cancer/Tumor Name?

PGX

Current medications.

Add More

Cardiac

Have you ever had an abnormal Echocardiogram (ECG) or Electrocardiogram (EKG) reading?

Year or approximate date of abnormal ECG/EKG reading

Do you have sudden cardiac arrest?

Have you been diagnosed with an abnormal heart beat?

Abnormal heart beat attributes

Arrhythmia

Long QT syndrome

Ventricular Tachycordia

Unknown

Have you ever been diagnosed with a heart attack?

Have you ever had a stroke?

Year of stroke

Do you have a pacemaker?

Do you have a stent?

Have you been diagnosed with AFib?

What type?

Have you ever been diagnosed with heart disease?

Have you ever had a heart bypass surgery?

Have you ever been diagnosed with cardiomyopathy?

Type of cardiomyopathy

Hypertrophic (Obstructive)

Dilated (Enlarged heart Chambers Due to Weakened Hheart)

Restrictive (Rigid Lower-chambers of the Heart)

ATTR-CM (Transthyretin Amyloid)

Other/Unknown

Have you been diagnosed or experienced any of the following conditions?

Hepatitis C

Age at Diagnosis

Acute bronchitis

Age at Diagnosis

Type 2 Diabetes

Age at Diagnosis

Did you experience complications from Diabetes?

What types of complications did you experience? (check all that apply)

Nerve Damage

Kidney Damage

Eye Damage

Hearing Imparment

Other Complications

Muscular dystrophy

Age at Diagnosis

Type of Muscular Dystrophy

Congenital (present at birth) myopathy (muscle disease)

Age at Diagnosis

Metabolic Myopathy

(A genetic disease that affects the metabolism due to lacking certain enzymes that provide energy to help muscles contract.)

Age at Diagnosis

Type of Myopathy

Lipodystrophy

Age at Diagnosis

Type of Lipodystrophy

Known Familial hypercholesterolemia genetic disorder

Do you have any family history of heart-related conditions?

Please list all family members that have history of heart-related conditions

Relationship

Family Side

Condition

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Have you experienced any cardiac chest pain?

Have you been diagnosed with High Cholesterol?

Have you ever been diagnosed with hypertension?

Current medications.

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Diabetes

Current medications.

Add More

Do you have diabetes?

What type of diabetes do you have?

(Including pre-diabetes, type-1, or type-2)

Age at Diagnosis

Did you experience complications from Diabetes?

What types of complications did you experience? (check all that apply)

Nerve Damage

Kidney Damage

Eye Damage

Hearing Imparment

Other Complications

Have you been diagnosed with High Cholesterol?

Have you experienced essential hypertension?

Have you ever been diagnosed with depression or depressive disorder?

Have you ever been diagnosed with anxiety or anxiety disorder?

Has your weight changed over the past year?

How so?

Do you have any family members that been diagnosed with any form of diabetes, obesity, or weight-related conditions?

Please list All of the diagnoses.

Relationship

Family Side

Age at Diagnosis

Living/Decesased

Disease type

Add More

Are you physicially active?

How many times a week do you participate in a physical activity?

Do you drink alcohol?

How many alcoholic beverages do you drink per week?

Do you use tobacco?

How many times do you use tobacco on an average day?

Do you eat fast food or have a high sugar diet?

Do you regularly feel tired or fatigued?

Do you often have excessive thirst?

Have you ever been diagnosed with Neuropathy?

(Tingling in your hands or feet)

Have you or a family member been diagnosed with a Leptin deficiency?

Have you ever had gastric bypass surgery?

When did you undergo the surgery.

Do you suffer from sleep apnea?

Have you been diagnosed with a MC4R deficiency?

When were you diagnosed with MC4R deficiency?

Have you ever been diagnosed with Retinopathy?

(Damage to the retina of the eyes)

Do you know what your A1C is?

What is your A1 C Number

PAD

Are you 50 years or older?

Do you smoke or have you ever smoked?

Have you been diagnosed with any of the following:

PAD (Peripheral Artery Disease)

Diabetes

Chronic kidney disease

High blood pressure

High cholesterol

Cardiac disease

Stroke

Do you have a family history of PAD?

Family History

Relationship

Family Side

Age at diagnosis

Add More

Do you experience tiredness, heaviness, or cramping in the leg muscles, especially during activity?

When you inspect your toes and feet, do they appear pale, discolored, or blue?

Do you experience leg pain?

Does it disturb your sleep?

Have you experienced sores or wounds on the toes, feet, or legs that heal slowly or not at all?

Does one leg or foot regularly feel colder than the other?

Have you noticed poor nail growth and decreased hair growth over time on the toes and legs?

CVI

Are your legs swollen, painful, red, or warm to the touch?

Have you had a blood clot in a vein that caused inflammation, pain, or irritation?

Do you have varicose veins (veins that are enlarged or swollen and raised above the surface of the skin) in the legs?

Have you ever had Deep Vein Thrombosis (DVT) in the past?

Have you experienced pain, swelling, changes in skin color, cellulitis, or non-healing ulcers?

Do your legs feel heavy, tired, restless, or achy?

Do you have swollen feet, ankles, or legs

If you press on your swollen area for 10 seconds and release, do your fingers leave a dimple?

Does the skin look stretched or shiny?

Do you have ulcers on the inside of your ankle?

APD

Have you been diagnosed with Parkinson’s disease, Alzheimer’s Disease, Huntington’s Disease, or Dementia?

Which have you been diagnosed with

Age of diagnosis

Do you have family members that have been diagnosed with Parkinson’s disease, Alzheimer’s Disease, Huntington’s Disease or Dementia?

Relationship

Family Side

Age at diagnosis

Disease Type

Add More

Have you ever experienced any of the following neurological symptoms? Check all that apply.

Abnormal Brain Imaging

Difficulty Moving (Motor functions)

Uncontrollable Movements

Memory Loss that interferes with daily life

Hand tremor at rest

Have you ever experienced any of the following psychiatric or memory conditions? Check all that apply.

Mood Changes or Mood Swings

Changes in Personality

Psychiatric Manifestations

Difficulty Holding Conversations

Difficulty Completing familiar and routine tasks

General Confusion of Place or Time

Have you ever experienced a seizure?

Year

Have you been diagnosed with Hypertension?

Have you been diagnosed with High Cholesterol?

Do you have diabetes?

What type of diabetes do you have?

Do you have any known genetic abnormalities or conditions?

Type

Do you have a known APOE Genotype?

Cardiopulmonary

Have you ever had a respiratory infection such as pneumonia or influenza?

Do you have trouble breathing? (To include wheezing, or shortness of breath)

Have you been diagnosed with pulmonary edema or early onset pulmonary emphysema?

Do you have heart disease or other heart problems?

Arrhythmia

Right-sided Heart Failure

Rapid Heartbeat

Heart Disease

Do you have swelling in the legs or belly area?

Do you experience fatigue?

Do you have any of the following breathing or lung conditions?

COPD

Bronchitis

Do you have any family history of lung or pulmonary conditions?

Family History

Relationship

Family Side

Age at Diagnosis

Condition

Add More

Covid-19

Do you currently have a fever of 100.4 or more?

Do you have a cough?

Are you experiencing shortness of breath?

Have you come into contact with anyone diagnosed with the coronavirus in the last 10 days?

Are you over the age 65?

Are you a first responder or medical professional?

Have you experienced any of these symptoms in the last 10 days?

Fever or feeling feverish (such as chills sweating)

Muscle aches or body aches

Unusual Fatigue

Headache

New loss of taste or smell

Congestion or runny nose

Nausea or vomiting

Diarrhea

When did your symptoms first appear (MM/DD/YYYY)

Did the infection require hospitalizations?

Do you live in a long-term care facility, nursing home, homeless shelter, or housing at an institute of higher education?

Have you been tested for Covid-19 in the last 10 days?

What were the results of your previous test?

Are you currently pregnant?

Is this your first test for Covid-19?

Was the patient admitted to intensive care unit (ICU) for Covid-19?

Covid/Flu

Do you currently have a fever of 100.4 or more?

Do you have a cough?

Are you experiencing shortness of breath?

Have you come into contact with anyone diagnosed with the coronavirus in the last 10 days?

Are you over the age 65?

Are you a first responder or medical professional?

Have you experienced any of these symptoms in the last 10 days?

Fever or feeling feverish (such as chills sweating)

Muscle aches or body aches

Unusual Fatigue

Headache

New loss of taste or smell

Congestion or runny nose

Nausea or vomiting

Diarrhea

When did your symptoms first appear (MM/DD/YYYY)

Did the infection require hospitalizations?

Do you live in a long-term care facility, nursing home, homeless shelter, or housing at an institute of higher education?

Have you been tested for Covid-19 in the last 10 days?

What were the results of your previous test?

Are you currently pregnant?

Is this your first test for Covid-19?

Was the patient admitted to intensive care unit (ICU) for Covid-19?

CGM

Current medications.

Add More

Do you have diabetes?

What type of diabetes do you have?

Do you currently use a blood glucose meter?

On average how many times per day do you test your blood glucose levels?

What type of glucose do you use?

Peanut Allergy

Do you have a known or suspected allergy to peanuts?

Have you had an anaphylactic reaction due to peanuts?

Do you have allergies to other foods besides peanuts?

What kind?

Peanut Allergy DTC

Has the individual been introduced to foods containing peanut?

Has the individual seen an allergist?

Has the individual been diagnosed with a peanut allergy in the past?

Has the individual been prescribed an epinephrine device for a peanut allergy?

Please list any diagnostic tests done in the past for a peanut allergy evaluation.
Our nurses will reach out to request a full list of the test results. You can also skip this step for now.

Was an Oral Food Challenge (OFC) conducted?

Has the individual been avoiding foods containing peanut?

Are you satisfied with your current peanut allergy treatment plan?

Does the individual have any other food allergies?

Does the individual have asthma?

Does the individual have eczema?

Has the individual been diagnosed with eosinophilic esophagitis?

Does the individual have any other medical conditions?
Please type 'N/A' if the individual does not have any other medical conditions.

Is the individual on Allergy Immunotherapy for environmental allergies?

Is the individual on any medications?

Current medications.

Add More

Is there any anxiety surrounding the diagnosis or treatment of food allergies for the individual or family member of the individual?

Has the individual been the target of teasing or aggressive behavior due to their food allergy?

Address *

Address Line 2

City *

State *

Zip *

Sex *

Height Ft.

Height In.

Weight lbs

Ethnicity *

Ethnicity Other

Emergency Contact

First Name

Last Name

Phone

Email

Relationship

Patient requests to be assigned to a physician, via telemedicine service, as the primary provider for this test request.

Patient requests to be assigned to a physician, via telemedicine service, if their PCP does not respond to the test request

Patient requests test review by PCP only

Search for Primary Care Physician

OR

Add New Primary Care Physician (PCP)

New Primary Care Physician

PCP First Name *

PCP last Name *

PCP NPI Look Up NPI

PCP Practice Name/Institution

PCP Phone

PCP Fax

PCP Address

PCP City *

PCP State *

PCP Zip

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Additional Notes

Submission Date

Additional Notes (optional)

Billing

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Acknoweledgements/Signature

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