NAD+ Intake Form Template
NAD+ (Nicotinamide Adenine Dinucleotide) is a critical coenzyme involved in cellular energy production, DNA repair, and sirtuin activation. It is administered via IV infusion, IM injection, or subcutaneous injection through compounding pharmacies for chronic fatigue, cognitive decline, anti-aging, and addiction recovery support. This intake form documents energy and cognitive symptoms and screens for contraindications including allergy and cancer history.
Free Template
NAD+ Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
NAD+ 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.
NAD+ for IV/IM use must be compounded by a licensed 503A or 503B pharmacy. Verify pharmacy licensure and purity documentation. See FDA: https://www.fda.gov/drugs/human-drug-compounding
IV NAD+ infusions can cause transient side effects including flushing, nausea, and chest tightness. Patients should be monitored during infusion.
Due to NAD+ role in cellular metabolism and sirtuin activation, use in active cancer patients requires specialist evaluation. See FSMB: https://www.fsmb.org
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Sources & References
Frequently Asked Questions
What are the benefits of IV NAD+ therapy?
IV NAD+ delivers the coenzyme directly into the bloodstream, bypassing GI absorption limitations. It is used for energy restoration, cognitive clarity, cellular repair support, and addiction recovery protocols.
Is NAD+ therapy FDA-approved?
NAD+ is not FDA-approved for the clinical indications listed above. It is compounded and administered off-label. Patients must provide informed consent acknowledging the investigational nature of the therapy.