VITB12 PRESCRIPTION REQUEST FORM
PLEASE COMPLETE DETAILS IN BOXES PROVIDED
First Name
Last Name
DOB
Phone Number
Email
Address
GP SURGERY FULL ADDRESS
MEDICATION - PLEASE LIST ANY YOU ARE CURRENTLY TAKING
CONTRA- INDICATIONS
PLEASE SELECT ANY CONTRA-INDICATIONS FOR IM HYDROXOCOBALAMIN B12 INJECTION THAT APPLY TO YOU
CONTRA-INDICATIONS
NONE
COBALT ALLERGY
COBALMIN AND DERIVATIVE ALLERGIES
LOW BLOOD POTASSIUM LEVELS
LEBER’S HEREDITARY OPTIC ATROPHY
PREGNANT
UNDER 18
UNDERGOING CANCER TREATMENT
INDICATIONS
PLEASE SELECT ANY INDICATIONS FOR IM HYDROXOCOBALAMIN B12 INJECTION THAT MAY APPLY TO YOU. IF 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)
INDICATIONS
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
BRUISE EASILY
CELIAC DISEASE
CHRONIC DAILY FATIGUE
CHRONIC PANCREATITIS
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
EARLY ONSET DEMENTIA
EARLY ONSET MENOPAUSE
EASILY DISTRACTED
ECZEMA, DRY SKIN RASHES
ERECTILE DYSFUNCTION
ESOPHAGEAL ULCERS
EVERYDAY DIARRHEA
FLATULENCE
FREQUENT HEARTBURN, DESPITE EATING HEALTHY
FREQUENT MISCARRIAGES, SPONTANEOUS ABORTIONS
FREQUENT STOMACH ACHES
FREQUENT STOMACH BLOATING
GASTRIC BYPASS SURGERY
HAIR LOSS NOT RELATED TO AGE
HALLUCINATIONS, DELIRIUMS
HEART PALPITATIONS THROUGHOUT DAY
HORMONAL IMBALANCES
HYPERHOMOCYSTEINEMIA
HYPERACUSIS
HYPERSENSITIVITY
HYPOTHYROID OR HYPERTHYROID DISORDER
INFERTILITY
INSOMNIA OR SPORADIC SLEEP
INTESTINAL BACTERIAL OVERGROWTH
LOSS OF APPETITE
LOW SPERM COUNT
MEMORY IMPAIRMENTS
MOOD SWINGS
NAUSEA
NEUROSIS, FIXATIONS
NIGHT TERRORS
OPTIC NEURITIS
PERNICIOUS ANEMIA
PINS AND NEEDLES
PMS
POOR CONCENTRATION, ADD- LIKE SYMPTOMS
POOR DEVELOPMENT IN NEWBORN BABY
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 TREAMENT (INCLUDE DETAILS BELOW)
COVID - 2 WEEKS CLEAR OF VACCINATION?
PLEASE TICK AS APPROPRIATE
YES
NO
VERIFICATION
PLEASE CHECK THAT ALL INFORMATION YOU HAVE PROVIDED IS CORRECT
PRINT NAME
DATE
SIGNED
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