ZOR Medication Request Survey ZORLearn about treatment options based on your goals, habits, and health history.Please select all medical conditions you have been diagnosed with (check all that apply) Please select all medical conditions you have been diagnosed with (check all that apply)A) Hypertension (High Blood Pressure)B) Diabetes MellitusC) Hyperlipidemia (High Cholesterol)Other:Clear selectionPlease list any prescription or over-the-counter medications you are currently taking Please list any prescription or over-the-counter medications you are currently takingClear selectionDo you have any known drug allergies? Do you have any known drug allergies?A) No known drug allergiesB) YesClear selectionList your allergies if you have any List your allergies if you have anyClear selection⏱ Medication Frequency & Timing SIGs ⏱ Medication Frequency & Timing SIGsA) QD – Once daily (e.g., every morning)B) BID – Twice daily (every 12 hours)C) TID – Three times daily (every 8 hours)D) QID – Four times daily (every 6 hours)E) QAM – Every morningF) QHS / HS – At bedtimeG) QOD – Every other dayH) TIW – Three times a week (e.g., Mon/Wed/Fri)I) BIW – Twice a week (e.g., Mon/Thu)J) QWK / Weekly – Once a weekK) QMO / Monthly – Once a monthL) QY / Yearly – Once a yearClear selectionYou are pregnant? You are pregnant?A) YesB) NoClear selectionPlease hold on while we get your product ready
