LDN Boost Intake Form Template
Low Dose Naltrexone (LDN) is used off-label for immune modulation, mood support, chronic fatigue, and appetite regulation. LDN Boost formulations combine low-dose naltrexone with complementary compounds to support overall wellness. This intake form documents symptoms including fatigue, depression, weight gain, and cravings, and screens for contraindications such as kidney disease, liver disease, heart problems, and eating disorders.
Free Template
LDN Boost Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
LDN Boost Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Contraindications
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
LDN is prescribed off-label and must be compounded by a licensed pharmacy. Naltrexone is FDA-approved at higher doses for opioid and alcohol use disorder; low-dose use requires informed consent. See FSMB: https://www.fsmb.org
Patients currently taking opioid medications cannot use naltrexone. Screen for opioid use before prescribing. See FDA Naltrexone labeling: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/018932s017lbl.pdf
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Sources & References
Frequently Asked Questions
What is Low Dose Naltrexone?
LDN refers to naltrexone taken at doses far below the standard opioid-blocking dose (typically 1.5-4.5 mg vs. 50 mg). At low doses it is studied for immune modulation, chronic pain, mood, and inflammatory conditions.
Can patients on opioids take LDN?
No. Naltrexone at any dose blocks opioid receptors and will precipitate withdrawal in patients taking opioid medications. Full opioid cessation is required before initiating naltrexone.