Wyoming Wellness Center

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Available Forms

First Contact / Info Request Form Medical and Psychosocial Intake Form Prescription Request/Questionnaire

Prescription Request/Questionnaire

Prescription Refill Request Form: Please allow 10 to 14 days for requests on all medications. APPOINTMENT REQUIREMENTS BELOW (In-Person or Telehealth): For LDN or other Non-Controlled Medications: Every 6 Months; For Buprenorphine & Ketamine: Every 3 Months; For Oxycodone, Hydrocodone, etc: Every Month. Please Call To Make Your Appt When Appropriate

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Demographic Info

Patient Name *

Must include first and last

Patient DOB *

Recent Weight: *

Prescription Info

What Medication(s) are you wanting Refilled or a New Script For? *

What Date will you Be OUT of your Medications? *

**If asking for multiple medications, Please list date of the Medication you will Run Out of SOONEST.

If we are able to: What Pharmacy do you want your Prescriptions sent to?

What Condition(s) are You Taking the REQUESTED Medication(s) For? *

Chronic Pain Condition

Anxiety/Depression/PTSD

Other Mental Health Condition

Restless Leg Syndrome

Autoimmune Disorder

Something Else

Not Currently Taking This Medication

If you chose "Something Else" - Explain in DETAIL or mark "NA"

Are You Wanting to CHANGE or ADJUST Your Medication(s) or Dosing of Medication(s)? *

NO, I'm Good with Everything

YES, I Want to Discuss CHANGING my Medication(s)

YES, I Want to Discuss ADJUSTING the Dosing of my Medication(s)

If you chose "YES" - Explain in DETAIL What You are Wanting to CHANGE/ADJUST with Your Medication(s) / Dosing, or mark "NA"

Pain or Symptom Control - SINCE LAST REFILL

How Would You Rate Your Pain or Symptom Control Since Your LAST REFILL? (0 = NO Control, 10 = Completely Controlled)

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How Well Has Your Medication(s) Worked in Controlling Your Pain or Symptoms? *

Not Working at All

Working Some of the Time

Working Most of the Time

Working Very Well/All the Time

Need to Explain - Please explain below

If you chose "Not Working at All" or "Need to Explain" - Explain in DETAIL or mark "NA"

What TIME OF DAY is your Pain or Symptoms the WORST? *

Morning

Afternoon

Evening

Night

No Difference in Time of Day

More Details about Times of Day Your Pain or Symptoms are Worse:

Select ALL Events/Actions that Make Your Pain or Symptoms WORSE.

Details of Events/Actions that Worsen your Pain or Symptoms WORSE

Life Events - SINCE LAST REFILL

Have ANY of the Following Life Events / Situations Happened SINCE YOUR LAST REFILL? *

Please give Details for Negative or Worsening Issues or "Something Else" Marked, or mark NA *

Medication Adherence

Have You Been Taking Your Medication(s) as Prescribed (On the Bottle or Provided Instructions)? *

Not at ALL

Some of the Time

Most of the Time

ALL the Time

Need to Explain

If you chose "Not at All" or "Some of the Time" or "Need to Explain" - Explain in DETAIL or mark "NA" *

Side Effects: Since LAST REFILL

Side Effects: Have You Experienced ANY NEW OR WORSENING of the Following Conditions, Since your LAST REFILL? *

Side Effects Related Prescription

If you Selected ANY SIDE EFFECTS Above, Do You Feel Those Symptoms are RELATED to or CAUSED by the Medication you are Requesting REFILLED? *

**Yes

**Not Sure

**Want to Talk with Tracy About This/These Symptoms and IF they could be Related to the medication I'm taking.

Further Communications

ANY OTHER INFORMATION to CONVEY or SHARE ABOUT YOUR PAIN CONTROL? or mark NA

* Required field