Please fill out the information below, then press "View Form" to review and print your information.

Patient Information

Patient Name

Date of Birth

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1. Physician's Name
Address

2. Are you under a physician's care? Yes No

3. When was your last complete physical exam?


4. Are you taking any medication or substances? Yes No
If yes, please list medications:


5. Do you routinely take health related substances? Yes No
(Vitamins, herbal supplements, natural products)

6. Are you allergic to any medications or substances? Yes No
If yes, please list:


7. Do you have any other allergies or hives? Yes No

8. Do you have any problems with penicillin, antibiotics, anesthetics or other medications? Yes No

9. Are you sensitive to metals or latex? Yes No

10. Are you pregnant or suspect you may be? Yes No

11. Do you use any birth control medications? Yes No

12. Do you currently or have you ever taken bisphosphonates for bone density (Fosomax)? Yes No

13. Have you ever been treated for or been told you might have heart disease? Yes No

14. Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse? Yes No

15.Have you ever had rheumatic fever? Yes No

16. Are you aware of any heart murmurs? Yes No

17. Do you have high or low blood pressure? Yes No

18. Have you ever had a serious illness or surgery? Yes No
If so, explain:


19. Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition? Yes No

20. Do you have inflammatory diseases, such as arthritis or rheumatism? Yes No

21. Do you have any artificial joints/prosthesis? Yes No

22. Do you have any blood disorders, such as anemia, leukemia, etc? Yes No

23. Have you ever bled excessively after being cut or injured? Yes No

24. Do you have any stomach problems? Yes No

25. Do you have any kidney problems? Yes No

26. Do you have any liver problems? Yes No

27. Are you diabetic? Yes No

28. Do you have fainting or dizzy spells? Yes No

29. Do you have asthma? Yes No

30. Do you have epilepsy or seizure disorders? Yes No

31. Do you or have you had venereal disease? Yes No

32. Have you tested HIV positive? Yes No

33. Do you have AIDS? Yes No

34. Have you had or do you test positive for hepatitis? Yes No

35. Do you or have you had T.B.? Yes No

36. Do you smoke, chew, use snuff or any other forms of tobacco? Yes No

37. Do you regularly consume more than one or two alcoholic beverages a day? Yes No

38. Do you habitually use controlled substances? Yes No

39. Have you had psychiatric treatment? Yes No

40. Have you taken any prescription drugs fenfluramine, fenfluamine combined with phentermine (fen-phen), dexfenfluramine (redux) or other weight loss products? Yes No

41. Do you have any disease, condition, or problem not listed? If so, explain:


42. Is there anything else we should know about your health that we have not covered on this form?


43. Would you like to speak to the doctor privately about any problem? Yes No