Vitamin B12 Patient Form Please enable JavaScript in your browser to complete this form.Title (Mr/Mrs/Ms/Miss/Dr) *Name *FirstLastDate of Birth *Phone *Email *Your Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeGP's Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeHave you had any COVID Vaccinations In the Last 2 Weeks? *YesNoIf Yes What Was The Date of the Last VaccinationMedications *Please list all medications you are currently taking, if none please state "None"Contra-IndicationsPlease Select Any Contra-Indications For Im Hydroxocobalamin B12 Injection That Apply To YouPlease Select All Contra-Indications That Apply *NoneCobalt AllergyCobalamin and Derivative AllergiesLow Blood Potassium LevelsLeber’s Hereditary Optic Atrophy PregnantUnder 18Undergoing Cancer TreatmentIndicationsPlease Select Any Indication For Im Hydroxocobalamin B12 Injection That Apply To You. If You Have No Symptoms Listed Below - Please Select ‘Other’ At The Bottom To Add Any Other Symptoms, Concerns That You Have And Reasons For Requesting Treatment (Such As Lack Of Energy/Trouble Sleeping Etc)Please Select All Indications That Apply *Celiac DiseaseDisease Recurrent Panic AttacksCrohn’s Disease AniextyChronic PancreatitisSore Tongue, Burning Mouth SensationGastric Bypass SurgeryRed Tongue That Is Abnormally SmoothHyehomocysteinemiaContinuous Mouth UlcersIntestinal Bactrical OvergrowthCracked Sores At Both Corners Of Your MouthPernicious AnemiaBad Breath, HalitosisStrict VegetarianAltered Palate, Food Tastes DifferentVeganStrange Thirst, Constantly DehydratedPins And NeedlesUnusual Metallic Taste In MouthDifficulty Building Muscle MassFrequent Stomach AchesDepression That Lasts Without Apparent CauseNauseaChronic Daily FatigueFrequent Stomach BloatingPoor Concentration, Addlike SymptomsDifficulty SwallowingEasily Distracted Acid Reflux That Occurs Regardless Of DietMood Swings Frequent Heartburn, Despite Eating HealthyMemory ImpairmentsFlatulenceAggressive Behaviour That Is New Or UnusualLoss Of AppetiteNeurosis, FixationsConstipationEarly Onset DementiaEveryday DiarrheaHallucinations, DeliriumsEsophageal UlcersYeast Infections That Occur OftenUnusual Weight Loss Or Weight GainEarly Onset MenopauseReduced LibidoAbnormally Pale Facial ComplexionHormonal ImbalancesHeart Palpitations Throughout The DayLow Sperm CountWeak PulseErectile DysfunctionHypothyroid Orhyperthyroid DisorderInfertilityHypersensitivity Post-Partum DepressionInsomnia Or Sporadic SleepFrequent Miscarriages, Spontaneous AbortionsNight TerrorsPoor Development In Newborn BabyBlurring Or Double VisionLanguage Impairments In ChildOptic NeuritisPmsTinnitusEczema, Dry Skin RashesHyperacusisPremature Grey HairAlways Feeling ColdHair Loss Not Related To AgeBruise Easily ThinRidged Nails That Break EasilyConstantly Itchy SkinOtherOther Reasons for Requesting Treatments Please Include Details AboveVerificationPlease Check That All Information You Have Provided Above Is Correct And Enter Your Name And Tick The Consent Button As A Digital SignaturePrint Your Name *Date *Confirmation *By Checking This Box I Confirm The Information I Have Given Is Correct To The Best Of My KnowledgeSubmit
