Bowel Health Assessment Form

Before we can ship your medication to you, we need to collect a few pieces of information about your health to make sure our compounded medicine is right for you.

Are you allergic to antihistamines?(Required)

Yes

What is your gender?(Required)

Date of birth?(Required)

Month

Day

Year

How many times a day do you have bowel movements?(Required)

1-2

3-5

6-10

10+

How painful are your bowel movements?(Required)

Mild

Moderate

Severe

None of the above

Your previous answer indicates that you're not having pain during bowel movements.

Are you having any digestive discomfort? If so can you give us a brief description? Leave blank if you're not having bowel discomfort.

Bathroom urgency can cause you to feel stressed or embarrassed, cancel plans, and not let you leave your home.

Do you feel sudden urges to have bowel movements?(Required)

Yes

Do these urges generally occur within 30 minutes of eating?(Required)

Yes

Do you have “restroom panic” or the need to identify the availability of restrooms wherever you go?(Required)

Yes

On of your answers indicate that you're not having urgency prior to bowel movements.

Please provide any additional information about your bowel movements that would help us understand your need for relief.

Please tell us more about your digestive system medical issues.

Do you currently have blood in your stool?(Required)

Yes

Have you been diagnosed with any of the following conditions?(Required)

IBS

Crohn's Disease

Colitis

Ulcerative Colitis

None of the above

Lastly, we need to know what medications you're currently taking and if you have any known allergies to any medications.

Are you taking any medications or supplements?(Required)

Yes

Medications/Supplements currently taken:(Required)

Do you have any drug allergies?(Required)

Yes

Drug Allergies:(Required)

Congratulations!

You've been pre-approved for SOLAMȲN™!

Your medical information is currently being reviewed by one of our partnered providers. If they have any questions about your assessment or once they determine whether one of our weight-loss medications is right for you, they will contact you through our secure messaging system on the My Account page.

-Dr. Reed Hogan III
Head of Provider Team