- CosmeticRX

Before we get started - How are you feeling today?

😄 Happy 🙁️ Sad 😧 Worried 🥱 Tired 😣 Stressed 😡 Angry 🤔 Not Sure

Evaluating your emotions will help you understand the feelings you experience, your thought patterns, your belief systems, and your behavior patterns better—a first step to mindfulness and an important aspect of mental health.

Is there a particular medication you are interested in or prefer?

No, I don't have a particular medication I am interested in Yes, I instead prefer

Now let’s get acquainted - Tell us about yourself

My name is Nice to Meet you

How much experience do you have with medication?

Not familiar, I have not previously used medication for mental health Somewhat familiar Very familiar

You're in the right place!

PHQ 1/8

Over the last 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

PHQ 2/8

Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

PHQ 3/8

Over the last 2 weeks, how often have you been bothered by trouble falling/staying asleep, or sleeping too much?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

PHQ 4/8

Over the last 2 weeks, how often have you been bothered by feeling tired or having little energy?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

PHQ 5/8

Over the last 2 weeks, how often have you been bothered by poor appetite or overeating?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

PHQ 6/8

Over the last 2 weeks, how often have you been bothered by feeling bad about yourself, that you are a failure, or have let yourself or your family down?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

PHQ 7/8

Over the last 2 weeks, how often have you been bothered by trouble concentrating on things such as reading newspapers or watching tv?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

PHQ 8/8

Over the last 2 weeks, how often have you been bothered by moving or speaking so slowly that other people have noticed, OR being so fidgety or restless that you have been moving around a lot more than usual?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 1/8

Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 2/8

Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 3/8

Over the last 2 weeks, how often have you been bothered by worrying too much about different things?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 4/8

Over the last 2 weeks, how often have you been bothered by trouble relaxing?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 5/8

Over the last 2 weeks, how often have you been bothered by being so restless that it is hard to sit still?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 6/8

Over the last 2 weeks, how often have you been bothered by becoming easily annoyed or irritable?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 7/8

Over the last 2 weeks, how often have you been bothered by feeling afraid as if something awful might happen?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

GAD7 8/8

In the past two weeks, how difficult have your problems made it for you to do work, take care of things at home, or get along with other people?

Select one that best describes

Not at all Several days More than half the days Nearly everyday

Anxiety results

Depression results

0/21

The GAD assessment is scored on a 0-21 scale. You scored 0/21, meaning you may be experiencing anxiety

This may fell like

Feeling anxious/on edge

Can’t help worrying

Constant worrying

Anxiety can affect the way you live, but it doesn’t have to stay that way. By working together, we’ll help you find ways to manage your symptoms.

0/21

The PHQ assessment is scored on a 0-21 scale. You scored 0/21, meaning you may be experiencing depression

This may fell like

Feeling anxious/on edge

Can’t help worrying

Constant worrying

Anxiety can affect the way you live, but it doesn’t have to stay that way. By working together, we’ll help you find ways to manage your symptoms.

Thank you for answering those questions. You’ve now set your baseline. Let's continue and take a closer look at your medical history and health.

What are the primary issues that brought you in today?

If you're unsure, pick the ones that feel closest to what you're experiencing

Persistent/excessive worry Depressed mood/ lost of interest in activities Panic attacks Insomnia Stress/ burned Grief Trauma Other

Have you been diagnosed or have a history of any of the following mental health conditions?

Telemedicine may not be suited to treat some conditions. It is important for you to tell us about your accurate history to help us understand if our platform is right for you.

Depression Generalized anxiety or other anxiety disorders ADD/ADHD Bipolar disorder Psychosis Schizophrenia/ Schizoaffective disorder Binge eating Borderline personality disorder Serotonin Syndrome

Please, tell me what your prior in current treatment for Depression?

How long have you been receiving treatment for Depression?

Can you describe how your Depression has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for Generalized anxiety or other anxiety disorders?

How long have you been receiving treatment for Generalized anxiety or other anxiety disorders?

Can you describe how your Generalized anxiety or other anxiety disorders has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for ADD/ADHD?

How long have you been receiving treatment for ADD/ADHD?

Can you describe how your ADD/ADHD has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for Bipolar disorder?

How long have you been receiving treatment for Bipolar disorder?

Can you describe how your Bipolar disorder has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for Psychosis?

How long have you been receiving treatment for Psychosis?

Can you describe how your Psychosis has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for Schizophrenia/ Schizoaffective disorder?

How long have you been receiving treatment for Schizophrenia/ Schizoaffective disorder?

Can you describe how your Schizophrenia/ Schizoaffective disorder has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for Binge eating?

How long have you been receiving treatment for Binge eating?

Can you describe how your Binge eating has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for Borderline personality disorder?

How long have you been receiving treatment for Borderline personality disorder?

Can you describe how your Borderline personality disorder has improved with treatment, and whether you have experienced any side effects from it?

Please, tell me what your prior in current treatment for Serotonin Syndrome?

How long have you been receiving treatment for Serotonin Syndrome?

Can you describe how your Serotonin Syndrome has improved with treatment, and whether you have experienced any side effects from it?

Have you been hospitalized for any mental health reasons and/or visited a crisis center or emergency room in the past?

Telemedicine may not be suited to treat some conditions. It is important for you to tell us about your accurate history to help us understand if our platform is right for you.

Yes No

Please pick all that applies below:

When was this psychiatric hospitalization?

What was the situation that led to the hospitalization?

How have you been feeling for the past few weeks?

Sad Anxious Worried Mad Irritable Unmotivated Emotional Stressed Afraid Tired Hypervigilant Apathetic

How has your sleep been?

Sleeping too much Sleeping too little Can’t fall asleep Can’t stay asleep Mid-night awakening Early-morning awakening

How has your appetite been?

Eating too much Eating too little Don’t have appetite Benging Not eating on purpose

Do you have a family history of mental health issues: depression, anxiety, bipolar, schizophrenia, substance abuse, etc?

No, I do not have a family history of mental health issues Not sure Yes

Who in your family has it? What were their symptoms, such as how they behaved? What medications or other treatments did they have?

Answer

Please list the name and the dose.

Answer

How long have you been taking it and have you seen improvement?

Answer

Your doctor needs to know whether you have any side effects from the medication(s). Have you had any side effects?

Answer

Do you want to continue your current medications?

Yes No, I want to change medications

Have you taken psychiatric medications in the past?

Answer

Is there a specific mental health medication you are interested in?

It is helpful for the provider to know if you have a specific treatment preference.

Yes No

Bupropion (Wellbutrin) Buspirone (BuSpar) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Venlafaxine (Effexor) Trazodone (Desyrel, Molipaxin) Other

Is there a specific dosage you are happy with?

Yes No

Please list the dosage

Please provide the other medication you are interested in

Are you currently taking other prescription medication, over-the-counter medication, supplements or herbal remedies ?

Yes No

What are the other prescription medications, over-the-counter medication, supplements or herbal remedies are you taking? Please list the exact names and dosage as seen on the prescription bottles.

What is your identified gender?

Man Woman Transgender man Transgender woman Gender queer/non-binary Agender Questioning Another gender

What was your sex assigned at birth?

For example on your original birth certificate.

Male Female

Are you currently pregnant or trying to conceive?

Yes No

Do you have or have you ever had any of the following medical conditions?

Select all that apply.

No, I do not have any of the below medical problems. Diabetes Enlarged prostate (benign prostate hyperplasia) Hair loss High blood pressure History of Hyponatremia Kidney failure Premature ejaculation QT prolongation Thyroid disease (diagnosed) Seizure No, I do not have any of these medical problems

When was your last seizure?

Is your blood pressure accurately controlled? Please provide the last blood pressure you remember.

Are you on dialysis?

Please provide your last A1C or your last blood sugar reading

Do you smoke or use other tobacco products?

This includes smoking, chewing, or vaping.

No, I don’t use tobacco products. Yes

What products do you smoke, and how much do you smoke per day?

How often in the last year have you had 4 or more alcoholic drinks on one occasion?

It is important for your provider to understand any potential interactions and impact on mental health symptoms.

Never A few times a year Once a month Daily or almost daily

Are you currently using any of the following recreational drugs?

It is important for your provider to understand any potential interactions and impact on mental health symptoms.

No, I do not use any of the substances below. Cannabis, marijuana, THC Cocaine Opiates/opioids (Heroin,Fentanyl,Oxycontin, pain medications) Poppers Stimulants (methamphetamines or illicit stimulants) Other

Have you ever had any surgeries or hospitalization?

No Yes

Please explain any hospitalizations. What was it for? How were you treated?

Do you have any allergies to medications, dyes, food or anything else?

Yes No

Please explain what the substance is and what your allergic reaction is.

In case of an emergency, is there someone you want us to contact?

Yes No

I understand the risk associated with an emergency and still prefer not to share an emergency contact.

Please share their name, their relationship to you, and phone number. By providing this information, you are providing CosmeticRx consent to contact this person in an event of an emergency or when applicable law requires us to contact them.

Answer

Is there anything else your provider should know to better tailor your treatment plan?

Is there anything else your provider should know to better tailor your treatment plan?

All set. Thanks

According to your clinical intake, it appears that you are experiencing symptoms of anxiety and depression

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

Some of the most widely used prescription medications are Escitalopram (Lexapro®), Sertraline (Zoloft®) and Citalopram (Celexa®). CosmeticRx has the guaranteed lowest price of any US telehealth company for a 3 month (90 days) supply .