- BoldRX

Next, let’s go through your health history.

Have you ever been told your kidneys are not working properly?

Yes No

Please describe in as much detail as possible. If available, include most recent creatinine and/or eGFR level.

Have you ever been told your liver is not working properly?

Yes No

Please describe in as much detail as possible. If available, include most recent ALT and AST levels

Have you ever been told your heart is not pumping properly?

Yes No

Please describe in as much detail as possible. If available, include the Ejection Fraction (EF) from your most recent echocardiogram and details on any other heart related procedures or diagnoses.

Do you currently smoke?

Yes No

How much and how often do you smoke?

Do any of your immediate family members have a history of the following conditions? (Check all that apply)

Cancer Heart Disease Stroke Diabetes High Blood Pressure High Cholesterol None of these

Have you had any of the following surgeries? (Check all that apply)

No past surgeries Back or Neck surgery Heart surgery or stenting Prostate surgery (Men only) Hysterectomy (Female only) Gallbladder Appendix Other

Please explain in more detail. When did this occur and why?

Do you have a primary care provider?

Yes No

Have you had a general health check-up or routine physical in the past three years?

Yes No

Prior to discovering BoldRx, how important was the idea of longevity or slowing down aging to you?

No importance/don’t care Very little importance Somewhat important Moderate importance Significant importance

Please list all medications you are currently taking or using.

Include any prescription and over-the-counter medications, supplements, implants, or patches.

Please list all allergies you have.

Which of the following best describes your main reason for seeking care with BoldRx?

I want to address a specific health issue (pain, fatigue, weight, etc.) I want to become a healthier version of me I want to remain and perform at peak health

What is your primary reason for requesting B12 Injection?

Increase Energy Improve Cognitive Function Reduce Fatigue Encourage Weight Loss Ease of Use Other

Please select if any of the following conditions apply:

Allergy to Vitamin B12 or Cobalt Leber's Hereditary Optic Neuropathy Central Vision Loss in the last 30 days Polycythemia Vera None of the above

Please provide details.

Have you ever used B12 by pill, patch, IV infusion, injection?

Yes No

Please explain which delivery mechanism(s) you have used in the past.

Have you ever given yourself an injection?

Yes No

Have you ever had problems using injections of any kind?

Yes No

Please explain.

Do you feel comfortable drawing up the B12 solution and injecting yourself using a needle?

Yes No

BoldRx's default protocol for B12 injections is subcutaneous (SC), however Intramuscular (IM) injections can be provided upon request. Please select a preference:

I have no preference or chose for me (we will default you to Subcutaneous) Subcutaneous (just under skin into fatty tissue) Intramuscular (into the muscle)

Which of the following apply to your reproductive status?

I am not currently pregnant nor am I breastfeeding. I am currently pregnant or breastfeeding. I plan to become pregnant or breastfeed within the next 6 months. I am currently going through menopause. I had a hysterectomy or am post-menopausal. I am a male (N/A).

How would you describe your diet?

Vegetarian Vegan Paleo Keto No Specific Diet Other

Please explain.

Have you ever been diagnosed with a B12 deficiency?

Yes No

Please explain.

Have you taken any heartburn medication for extended use (prescription or OTC)?

Yes No

Please explain.

Is there anything else you want your prescriber to know about your condition or health?

Yes No

Please explain.

All set. Thanks

You are not alone. Those with comparable symptoms often benefit from medication. We will now have one of the Board-Certified doctors at BoldRx.com review your consultation.

Are you a new or existing user to BoldRx

I am a new user I am an existing user