- BoldRX

Next, let’s go through your health history.

How physically active are you?

Sedentary Somewhat active Active but not athletic Athletic Competitive/biohacker

Please provide your height and weight.

Your height

Feet Inches

Your current weight

Pounds

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 in as much detail as possible. If available, include most recent creatinine and/or eGFR level.

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

Yes No

Please describe in as much detail as possible. If available, include most recent ALT and AST levels

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

Yes No

Please describe in as much detail as possible. If available, include the Ejection Fraction (EF) from your most recent echocardiogram and details on any other heart related procedures or diagnoses.

Do you currently smoke?

Yes No

How much and how often do you smoke?

Do any of your immediate family members have a history of the following conditions? (Check all that apply)

Cancer Heart Disease Stroke Diabetes High Blood Pressure High Cholesterol None of these

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

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

Please explain in more detail. When did this occur and why?

Do you have a primary care provider?

Yes No

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

Yes No

Prior to discovering BoldRx, how important was the idea of longevity or slowing down aging to you?

No importance/don’t care Very little importance Somewhat important Moderate importance Significant importance

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.

Which of the following best describes your main reason for seeking care with BoldRX?

I want to address a specific health issue (pain, fatigue, weight, etc.) I want to become a healthier version of me I want to remain and perform at peak health

What is your primary reason for requesting NAD Injection?

Faster recovery Increase Energy Increase Physical Endurance Improve Cognitive Function Improve mood Longevity Benefits Improve Fertility Other

Do you have a personal history of cancer?

Yes No

Please provide details such as type of cancer, date of diagnosis, and whether you are in remission.

Do you have a family history of cancer?

Yes No

Have you ever used NAD+ by patch, IV infusion, injection or nasal spray?

Yes No

Please describe and include any reactions, side effects and/or benefits you may have experienced

Have you ever given yourself an injection?

Yes No

Please describe the type of injection and why it was administered

Have you ever had problems using injections of any kind?

Yes No

Please explain.

Do you feel comfortable drawing up the NAD+ solution and injecting yourself using a small needle and syringe?

Yes No

Which of the following apply to your reproductive status?

I am not currently pregnant nor am I breastfeeding. I am currently pregnant or breastfeeding. I plan to become pregnant or breastfeed within the next 6 months. I am currently going through menopause. I had a hysterectomy or am post-menopausal. I am a male (N/A).

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

Yes No

Please explain.

All set. Thanks

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