Medical Intake — Reborn Rx

Question 1 of 11

What brings you to Reborn Rx?

This helps your clinician understand what you are hoping for. It does not determine whether you are prescribed anything.

Low energy or mental fogPersistent, and not explained by something obvious Recovery and general resilienceBouncing back more slowly than you used to Curiosity about the longevity researchYou have read about NAD+ and want a clinician’s honest read I’m already on NAD+ and want to transfer careContinue treatment with a new care team

Completing this intake does not create a prescription and does not guarantee you will be prescribed any medication. A licensed clinician makes that determination, and your clinician may request laboratory testing first. NAD+ is not approved to treat any condition, and no outcome is promised.

Question 2 of 11

Where are you located?

Telehealth is regulated state by state. We match you only with a clinician who holds an active license in the state where you are physically located.

State of residence

Reborn Rx serves adults physically located in the United States only. We cannot provide care to patients outside the U.S., including U.S. citizens traveling abroad.

Question 3 of 11

Date of birth

Reborn Rx treats adults 18 and older. Your date of birth is also part of your medical record and is used for clinical decision-making.

All fields are required unless marked optional.

Date of birth

Sex assigned at birth

Female Male

We ask about sex assigned at birth because it affects dosing, lab reference ranges, and pregnancy-related screening. You can tell your clinician your gender identity and pronouns at any point in your care.

Question 4 of 11

Height and weight

Used to establish a body composition baseline and to calculate dosing. This is one input among many, and it is not the basis for a treatment decision.

All fields are required unless marked optional.

Height

ft in

Current weight

lbs

Baseline BMI

Enter your height and weight

—

Waist circumference (optional)

in

Measured at the navel, if you have a tape to hand. Central body composition is one of the things tracked over time. Reborn Rx does not promise any change in body composition.

Question 5 of 11

Have you experienced any of these?

Select all that apply. Every one of these has many possible causes, and reporting them does not mean NAD+ is the answer — part of your clinician’s job is to consider what else could explain them. If none apply, continue without selecting anything.

Persistent fatigue or low energyLasting weeks or months, not explained by sleep or workload Brain fog, poor concentration, or memory changes Slower recovery from exercise, illness, or injury Poor or unrefreshing sleep Low mood or reduced motivation Widespread aches or muscle soreness I have had these symptoms investigated alreadyBloodwork, imaging, or a specialist referral None of these — I am well and simply interested

Fatigue and brain fog overlap heavily with thyroid disease, anemia, iron or B12 deficiency, sleep apnea, depression, and diabetes. Those are worth finding, because they are treatable. Your clinician may tell you to pursue that first.

Question 6 of 11

Safety screening

Answer carefully — this section directly affects whether treatment can be offered to you.

Answer honestly. These questions exist to protect you. Withholding or falsifying medical history can lead to serious harm and is grounds for removal from the program.

Because NAD+ supports the metabolism of every cell, and its effect on tumor behavior is unresolved, we do not prescribe during active cancer and require oncology clearance after a previous diagnosis.

Question 7 of 11

Current medications and allergies

Include prescriptions, over-the-counter medicines, vitamins, peptides, and supplements. Interactions with injected NAD+ have not been systematically studied, so your clinician needs the full list.

All fields are required unless marked optional.

Medications and supplements you take regularly

If you take none, write “none”.

Drug allergies or reactions

Do you currently take an NAD+ precursor such as nicotinamide riboside (NR) or nicotinamide mononucleotide (NMN)?

Yes No

Question 8 of 11

Have you taken NAD+ or a similar therapy before?

Prior exposure — by injection, IV infusion, or oral precursors such as NR or NMN — affects your starting dose and how your clinician reads your response.

NeverThis would be my first time I’m taking it nowInjections, IV infusions, or an oral precursor — you’ll be asked for details I took one in the past and stopped I stopped because of side effectsYour clinician will want the details before considering treatment

Details (optional)

Question 9 of 11

A little about your daily life

Sleep, alcohol, and training all affect how your cells produce energy, which is the same system NAD+ acts on. Your plan will address them either way.

How often do you exercise?

Rarely or never 1–2 times a week 3–4 times a week 5 or more times a week

Which of these describe you?

I usually sleep fewer than 6 hours a night My sleep is broken or unrefreshing I work night shifts or rotating shifts I do resistance training at least twice a week

Question 10 of 11

How should your care team reach you?

Your clinician may need to follow up before making a decision. Please use contact details you check regularly.

All fields are required unless marked optional.

Legal first name

Legal last name

Email address

Mobile phone

Used for appointment reminders and clinical follow-up. Standard message and data rates may apply.

Question 11 of 11

Review and consent

Please read each item. You must agree to the first three to submit your intake for clinical review.

State—
Date of birth—
Height & weight—
Baseline BMI—
Symptoms reported—
Safety flags reported—
Prior GH / peptide use—

Your responses are transmitted over an encrypted connection and stored in a HIPAA-compliant medical record. Reborn Rx does not sell your personal health information.

We need a clinician to look at this first

Based on your safety screening, NAD+ may not be safe for you. We have flagged your file for direct clinical review rather than moving you forward automatically.

Because NAD+ supports the metabolism of every cell and its effect on tumor behavior is unresolved, it is not appropriate during active cancer, and a previous cancer diagnosis requires oncology clearance first. It is also unsuitable during pregnancy and breastfeeding, or after a serious allergic reaction to a similar injectable. Your answers indicate at least one of these applies to you.

What we’ll do

A Reborn Rx clinician will contact you within one business day to confirm your history and discuss options, which may include a different treatment approach or a referral to in-person care. There is no charge for this review, and nothing has been billed.

Return to Reborn Rx Or call 1-877-671-5767

If you are pregnant or think you may be, tell your clinician before starting any medication. If you are experiencing a medical emergency, call 911.