Medication Clearance Self-Report Form
Please complete this form to self-report your readiness to use medication or to indicate if you should seek medical advice before use.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Do you have any known allergies to medications?
*
Yes
No
Please list any medication allergies (if applicable):
Are you currently taking any prescription or over-the-counter medications?
*
Yes
No
Please list your current medications (if applicable):
Do you have any of the following conditions? (Select all that apply)
*
Liver disease
Kidney disease
Heart condition
Seizure disorder
None of the above
Other
Are you currently pregnant or breastfeeding?
Pregnant
Breastfeeding
Neither
Have you recently had surgery or been hospitalized?
Yes
No
Based on your responses, do you believe you can safely use this medication, or should you seek medical advice before use?
*
I can safely use this medication
I should seek medical advice before use
Submit Self-Report
Should be Empty: