Pharmacy

Step 1 of 11

First name (required)

Last name (required)

Gender (required)

Email (required)

Date of birth (required)

Phone (required)

Street (required)

City (required)

State (required)

Zip code (required)

By checking this box and proceeding with the questionnaire, I agree to receive valuable information via email regarding the Transform Medical Weight Loss program including educational, event, and promotional information. I understand that I can opt out from these emails at any time

By checking this box, I understand that my prescriber may choose to initiate therapy with acompounded medication. I have read and understand the compounded medication disclosure statement

Clinician code

Please enter the clinician code to proceed.

Compounded medication disclosure statement

As part of our disclosure we want to reinforce that there are two basic categories of drugs that can be ordered via prescription; commercially available drugs and compounded medications. Commercially available drugs are:

Manufactured by U.S. Food and Drug Administration (FDA) inspected companies that are deemed to be compliant with FDA Current Good Manufacturing Practices.
Typically obtained by patients via prescription at traditional retail pharmacies such as Wal-Mart, CVS, Walgreens etc.
Reviewed by the FDA for safety and efficacy.
Approved by the FDA for one or more specific indications and contain package inserts that may explain usage, contraindications, warnings, precautions, adverse reactions and drug incompatibilities.

Compounded medications are:

Prepared by pharmacies that operate under state law, United States Pharmacopeia (USP) requirements and USP Good Compounding Guidelines.
Typically obtained by patients from licensed pharmacies that are equipped to compound drugs
Provided based on the medical need of an individual patient
Not reviewed by the FDA or State Boards of Pharmacy for safety and efficacy.
Not approved by the FDA for any indication and do not contain FDA reviewed package inserts that may explain usage, contraindications, warnings, precautions, adverse reactions and drug incompatibilities.

Health care professionals should also take appropriate steps to educate their patients when a compounded medication is prescribed.

The physician should inform the patient that a physician has the right to prescribe compounded medications based upon his/her knowledge of the patient’s health and his/her professional knowledge of the medication prescribed.

Additionally, the patient should be advised that the compounded medication:

Is provided based upon the medical need of the individual patient.
Is prepared by a licensed pharmacy.
Has not undergone the FDA’s New Drug Application process and has not been reviewed or approved by the FDA for safety or efficacy.

Please let us know if you have any questions about our disclosure policy. You may call us at 800-542-5767 or email us at info@rxcompound.com

Step 2 of 11

1. Are you currently taking any opioid pain medications? (examples: hydrocodone, morphine, oxycodone, codeine, tramadol, Vicodin)

Yes

2. Do you have a history of seizures?

Yes

3. Are you currently pregnant or trying to become pregnant?

Yes

4. Are you currently breastfeeding or nursing?

Yes

5. Are you taking any Hormone Replacement Therapy (HRT) currently? (Examples: hormone creams, pellets, injections, or pills containing estradiol, progesterone, testosterone, Premarin, Estrace)

Yes

6. Are you interested in Hormone Replacement Therapy (HRT)? (Hormonal imbalance may be an underlying cause for weight gain. Hormone imbalance is not addressed through most weight loss products)

Yes

Step 3 of 11

1. Are you currently taking any of the following medications?
PROZAC (Fluoxetine)
ZOLOFT (Sertraline)
PAXIL (Paroxetine)
CELEXA (Citalopram)
LEXAPRO (Escitalopram)
LUVOX (Fluvoxamine)
TRINTELLIX (Vortioxetine)

Yes

2. Are you currently taking any of the following medications?
GEODON (Ziprasidone)
SEROQUEL (Quetiapine)
ZYPREXA (Olanzapine)
RISPERDAL (Risperidone)
LATUDA (Lurasidone)
ABILIFY (Aripiprazole)
REXULTI (Brexpiprazole)
VRAYLAR (Cariprazine)
CLOZARIL (Clozapine)
SAPHRIS (Asinapine)

Yes

3. Are you currently taking any of the following medications?
CYMBALTA (Duloxetine)
EFFEXOR (Venlafaxine)
PRISTIQ (Desvenlafaxine)
SAVELLA (Milnacipran)
FETZIMA (Levomilnacipran)

Yes

Step 4 of 11

1. Sleep Induction (the time it takes you to fall asleep after turning off the lights)

No Problem

Slightly Delayed

Considerably Delayed

Very Delayed/Did Not Sleep at All

2. Awakenings during the night

No Problem

Minor Problem

Considerable Problem

Serious Problem/Did Not Sleep at All

3. Final awakening earlier than desired (waking up earlier than you wanted in the morning)

No Problem

A Little Earlier

Markedly Earlier

Much Earlier/Did Not Sleep at All

4. Total Sleep Duration

Sufficient

Slightly Insufficient

Markedly Insufficient

Very Insufficient/Did Not Sleep at All

5. Overall Quality of Sleep (no matter how long you slept)

Satisfactory

Slightly Unsatisfactory

Markedly Unsatisfactory

Very Unsatisfactory/Did Not Sleep at All

6. Sense of Well-Being During the Day

Normal

Slightly Decreased

Markedly Decreased

Very Decreased

7. Functioning (Physical and Mental) During the Day

Normal

Slightly Decreased

Markedly Decreased

Very Decreased

8. Sleepiness During the Day

None

Mild

Considerable

Intense

Step 5 of 11

1. When I play sport or games, I really try to win against whoever I play

Yes

2. I find myself thinking about problems even when I am supposed to be relaxing

Yes

3. My appetite has changed. I have either a desire to binge or have a loss of appetite / may skip meals

Yes

4. I find myself grinding my teeth

Yes

5. I frequently have guilty feelings if I relax and do nothing

Yes

Step 6 of 11

I don’t think about food a great deal.

I have strong cravings for food but they only last for brief periods of time.

I have days when I can’t seem to think about anything else but food.

Most of my days seem to be preoccupied with thoughts about food. I feel like I live to eat.

I don’t feel any guilt or self-hate after I overeat.

After I overeat, occasionally I feel guilt or self-hate.

Almost all the time I experience strong guilt or self-hate after I overeat.

I don’t lose total control of my eating when dieting even after periods when I overeat.

Sometimes when I eat a “forbidden food” on a diet, I feel like I “blew it” and eat even more.

Frequently, I have the habit of saying to myself, “I’ve blown my diet, why not go all the way?” When that happens, I eat even more.

I have a regular habit of starting strict diets for myself, but I break the diets by going on an eating binge. My life seems to be either a “feast” or “famine”.

I rarely eat so much food that I feel uncomfortably stuffed afterwards.

Usually about once a month, I eat such a quantity of food, I end up feeling very stuffed.

I have regular periods during the month when I eat large amounts of food, either at mealtime or at snacks.

I eat so much food that I regularly feel quite uncomfortable after eating and sometimes a bit nauseous.

I don’t think much about trying to control unwanted eating urges.

At least some of the time, I feel my thoughts are preoccupied with trying to control my eating urges.

I feel that frequently I spend much time thinking about how much I ate or about trying not to eat anymore.

It seems to me that most of my waking hours are preoccupied by thoughts about eating or not eating. I feel like I am constantly struggling not to eat.

I don’t have any problem stopping eating when I feel full.

I usually can stop eating when I feel full, but occasionally overeat leaving me feeling uncomfortably stuffed.

I have a problem stopping eating once I start, and usually I feel uncomfortably stuffed after I eat a meal.

Because I have a problem not being able to stop eating when I want, I sometimes have to induce vomiting to relieve my stuffed feeling.

I usually know whether or not I’m physically hungry. I take the right portion of food to satisfy me.

Occasionally, I feel uncertain about knowing whether or not I’m physically hungry. At these times it’s hard to know how much food I should take to satisfy me.

Even though I might know how many calories I should eat, I don’t have any idea what is a “normal” amount of food for me.

My level of calorie intake does not go up very high or go down very low on a regular basis.

Sometimes after I overeat, I will try and reduce my caloric intake to almost nothing to compensate for the excess calories I’ve eaten.

I have a regular habit of overeating during the evening. It seems my routine is not to be hungry in the morning but overeat in the evening.

In my adult years, I have had week-long periods where I practically starve myself. This follows periods when I overeat. It seems I live a life of either “feast or famine”.

Step 7 of 11

1. I frequently bring work home at night

Yes

2. I underestimate how long it takes to do things

Yes

3. If something or someone really annoys me I will bottle up my feelings

Yes

4. I have muscle aches and pains especially in the neck, head, lower back, shoulders

Yes

5. My sex drive is lower (men and women), I have experienced changes to my menstrual cycle (women)

Yes

Step 8 of 11

1. If I feel nervous, I try to calm down by eating.

Definitely true

Mostly true

Mostly false

Definitely false

2. When I feel lonely, I console myself by eating.

Definitely true

Mostly true

Mostly false

Definitely false

3. When I feel depressed, I want to eat.

Definitely true

Mostly true

Mostly false

Definitely false

Step 9 of 11

1. I often nod or finish other people’s sentences for them when they speak slowly

Yes

2. I find I have a greater dependency on alcohol, caffeine, nicotine or drugs

Yes

3. I find that I don’t have time for many interests / hobbies outside of work

Yes

4. I am unable to perform tasks as well as I used to, my judgment is clouded or not as good as it was

Yes

5. There are not enough hours in the day to do all the things that I must do

Yes

Step 10 of 11

1. I start to eat when I feel anxious.

Definitely true

Mostly true

Mostly false

Definitely false

2. When I feel tense or “wound up”, I often feel I need to eat

Definitely true

Mostly true

Mostly false

Definitely false

3. When I feel sad, I often eat too much.

Definitely true

Mostly true

Mostly false

Definitely false

Step 11 of 11

I don’t have the habit of eating when I’m bored.

I sometimes eat when I’m bored, but often I’m able to “get busy” and get my mind off food.

I have a regular habit of eating when I’m bored, but occasionally, I can use some other activity to get my mind off eating.

I have a strong habit of eating when I’m bored. Nothing seems to help me break the habit.

I usually am able to stop eating when I want to. I know when “enough is enough”

Every so often, I experience a compulsion to eat which I can’t seem to control.

Frequently, I experience strong urges to eat which I seem unable to control, but at other times I can control my eating urges.

I feel incapable of controlling urges to eat. I have a fear of not being able to stop eating voluntarily.

I eat 3 meals a day with only an occasional between meal snack.

I eat 3 meals a day, but I also normally snack between meals.

When I am snacking heavily, I get in the habit of skipping regular meals.

There are regular periods when I seem to be continually eating, with no planned meals.

I don’t feel self-conscious about my weight or body size when I’m with others.

I feel concerned about how I look to others, but it normally does not make me feel disappointed with myself.

I do get self-conscious about my appearance and weight which makes me feel disappointed in myself.

I feel very self-conscious about my weight and frequently, I feel intense shame and disgust for myself. I try to avoid social contacts because of my self-consciousness.

I seem to eat just as much when I’m with others (family, social gatherings) as when I’m by myself.

Sometimes, when I’m with other people, I don’t eat as much as I want to eat because I’m self-conscious about my eating

Frequently, I eat only a small amount of food when others are present, because I’m very embarrassed about my eating.

I feel so ashamed about overeating that I pick times to overeat when I know no one will see me. I feel like a “closet eater”

I feel capable to control my eating urges when I want to.

I feel like I have failed to control my eating more than the average person.

I feel utterly helpless when it comes to feeling in control of my eating urges.

Because I feel so helpless about controlling my eating, I have become very desperate about trying to get in control.

I’m usually physically hungry when I eat something.

Occasionally, I eat something on impulse, even though I’m really not hungry.

I have the regular habit of eating foods to satisfy a hungry feeling, even though physically I don’t need the food.

Even though I’m not physically hungry, I get a hungry feeling in my mouth that only seems to be satisfied when I eat a food, like a sandwich, that fills my mouth. Sometimes, when I eat the food to satisfy my mouth hunger, I then spit the food out so I won’t gain weight.

I don’t have any difficulty eating slowly in the proper manner.

Although I seem to “gobble down” foods, I don’t end up feeling stuffed because of eating too much.

At times, I tend to eat quickly and then, I feel uncomfortably full afterwards.

I have the habit of bolting down my food, without really chewing it. When this happens I usually feel uncomfortably stuffed because I’ve eaten too much.

Pharmacy Solutions This information will let us know more about you.

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Clinician code

Compounded medication disclosure statement

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Pharmacy Solutions
This information will let us know more about you.