Wyoming Wellness Center

Please allow 10 days for requests on all current medications. **AN APPOINTMENT MAY BE REQUIRED BEFORE REFILL CAN BE SENT - SEE BELOW** For Opioids & Ketamine - Every Month (Updox or phone) Check-Ins, THEN Every 6 Month Appointments (Telehealth or In-Person). For LDN or Other medications - Every 3 - 6 month (Updox or phone) Check-Ins, THEN Every 12 month Appointments (Telehealth or In-Person).

Patient Name * Patient DOB * If Requesting a NON-Compounded Medication: What Pharmacy do you want Script sent to? * What Medication(s) are you wanting Refilled or a New Script For? * What are the Conditions You are Taking the REQUESTED Medication(s) For? * If you chose "Something Else" - Explain in DETAIL or mark "NA" How Would You Rate Your Pain or Symptom Control Since Your LAST REFILL? (0 = NO Control, 10 = Completely Controlled) How Well Has Your Medication(s) Worked in Controlling Your Pain? * If you chose "Not Working at All" or "Need to Explain" - Explain in DETAIL or mark "NA" Have ANY of the Following Events / Situations Happened SINCE YOUR LAST REFILL? * Please give Details for Negative or Worsening Issues or "Something Else" Marked, or mark NA * What Time of Day is your Pain or Other Symptoms Worse? * More Details about Times of Day, Pain or Other Symptoms, are Worse: Select ALL the Events that Make Your Pain or Other Symptoms Worse. * Details on Events that Worsen your Pain or Other Symptoms, or Mark NA Are You Wanting to CHANGE or ADJUST Your Medication(s) or Dosing of Medication(s)? * If you chose "YES" - Explain in DETAIL What You are Wanting to CHANGE/ADJUST with Your Medication(s) / Dosing, or mark "NA" Have You Been Taking Your Medication(s) as Prescribed (On the Bottle or Provided Instructions)? * If you chose "Not at All" or "Some of the Time" or "Need to Explain" - Explain in DETAIL or mark "NA" * Have You Experienced ANY NEW OR WORSENING of the Following Conditions, Since your LAST REFILL? If you Selected ANY of the Symptoms Above, Do You Feel Those Symptoms are RELATED to or CAUSED by the Medication you are Requesting REFILLED? * ANY OTHER INFORMATION to CONVEY or SHARE ABOUT YOUR PAIN CONTROL? or mark NA