Niacin Supplement Intake Form
Please provide details about your use of niacin supplements.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Niacin Supplement Name or Brand
*
Niacin Form
*
Please Select
Nicotinic Acid
Nicotinamide (Niacinamide)
Inositol Hexanicotinate
Other
Niacin Dosage (mg per dose)
*
How often do you take the niacin supplement?
*
Please Select
Daily
Every other day
A few times per week
Occasionally
Other
When do you usually take it?
Please Select
Morning
Afternoon
Evening
Before bed
Varies
How long have you been taking this niacin supplement?
Please Select
Less than 1 month
1–3 months
4–12 months
More than 1 year
What is your main reason for taking niacin?
List any other supplements or medications you currently use.
Have you noticed any side effects or reactions?
Submit
Should be Empty: