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Required Personal Information:
Very important: You will only be approved for Reductil if you are overweight. The doctor will only prescribe Reductil to those individuals that are overweight with a BMI score greater than 27. (BMI or Body Mass Index is a measure of body fat base on height and weight that applies to both men and women). As a baseline a women that weighs 75 kilograms with a height of 1.65 metres has a BMI score equal to 27 (which indicates she is overweight and would benefit from Reductil.) Example: 1.65m --- 75 kg = BMI 28 (This represents the minimum BMI score needed for approved.)
Height:	1in = 2.54cm (required)
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Medical History: Please read the following list of medical conditions carefully. Be sure to give the appropriate explanations if your answer is "yes" to any of the following.
Do you or any of your immediate family have a history of the following medical conditions?
Blood disorders e.g. anemia, hemophilia, hemochromatosis, phlebitis, sickle cell anemia, thalassemia, thrombosis, hypercholesterolemia, etc.
Cancer e.g. brain, breast, bladder, colorectal, endometrial, leukemia, lung, lymphoma, multiple myeloma, ovarian, prostate, skin, testicular, etc.
Cardiovascular disease e.g. angina, arrhythmia, atrial fibrillation, claudication, congestive heart failure, valve disorder, heart attacks, high blood pressure, strokes, etc.
Endocrine disorder e.g. diabetes, goiter, hyperthyroidism, hypothyroidism, pheochromocytoma, thyroiditis, etc.
Eye disorders e.g. cataracts, glaucoma, retinal complications, etc.
Gastrointestinal disorder e.g. acid reflux, hiatal hernia, irritable bowel syndrome (Crohn's disease, ulcerative colitis), polyps, rectal bleeding, ulcers, etc.
Genitourinary disorder e.g. benign prostatic hyperplasia, cysts, endometriosis, pelvic inflammatory disease, etc.
Immune disorders e.g. Hashimoto's disease, eczema, HIV, Graves disease, Sjogrens syndrome, sarcoidosis, sclerodoma, etc.
Kidney (urinary tract) disorder e.g. bladder disorders, cystic disease, glomerular disease, nephrotic syndrome, renal failure, urinary tract complications, etc.
Liver disorder e.g. cirrhosis, Gilbert's syndrome, hepatitis, hemochromatosis, Wilson's disease, etc.
Musculoskeletal e.g. arthritis, back/spine complications, fibromyalgia, gout, lyme disease, muscular dystrophy, myasthenia gravis, osteomalacia, osteoporosis, rickets, spinal cord injury, etc.
Neurological disorder e.g. Alzheimer's disease, epilepsy, head injuries, headaches, Huntington's disease, multiple sclerosis, seizure, etc.
Psychological disorder e.g. anxiety, attention deficit disorder, bipolar disorder, depression, obsessive compulsive disorder, panic disorder, post traumatic stress disorder, etc.
Respiratory disorder e.g. allergic rhinitis, asthma, chronic bronchitis, emphysema, tuberculosis etc.
Other e.g. acne, chemical dependency, menopause, nutritional disorder, obesity, pregnant/nursing, significant trauma, etc.
Do you have a history of any of the medical conditions previously mentioned including Blood disorders, Cancer, Cardiovascular disease, Endocrine disorder, Eye disorders, Gastrointestinal disorder, Genitourinary disorder Immune disorders, Kidney (urinary tract) disorder, Liver disorder Musculoskeletal, Neurological disorder, Psychological disorder, Respiratory disorder, Other conditions (not mentioned)? If yes, please explain. For example, duration of illness, any surgery or treatment (ten year history of hypertension (high blood pressure), Atenolol 50mg one per day - well controlled with medications, Blood pressure 132/84):	Yes No
	0000000

Additional Medical: Please read the following list of medical questions carefully. Be sure to give the appropriate explanation if your answer is "yes" to any of the following.
Currently, are you taking any medications (this includes over-the-counter or nonprescription medication, herbal supplements, sports supplements, etc.) If yes, please explain(medication, supplement including dosage):	Yes No
Are you allergic to any medications, supplements or food products? If yes, please explain (medication, supplement, and the allergic reaction experienced):	Yes No
Do you consume more than two servings of alcohol per day or use tobacco products? If yes, please quantify type of product and usage:	Yes No
Do you currently follow a routine exercise program? If yes, please quantify type and amount of exercise (without the use of commas):	Yes No
	0000000

Reductil Specific Questions: Our doctors and staff are dedicated to providing you with the necessary information and resources to make intelligent decisions concerning your health. Although the general use of Reductil is very safe, you should realize that there are certain medical conditions in which Reductil is not appropriate. Please answer the following questions so our staff doctors can make the appropriate decision concerning your use of Reductil.
Currently, are you following any type of diet program or have you been on any diets in the past? If yes, please explain (without the use of commas):	Yes No
Do you have a history of any eating disorders e.g. anorexia, bulimia, etc.? If yes, please explain:	Yes No
Do you have any history of cardiovascular complications (heart attack, congestive heart failure, unstable angina [chest pain], arrhythmia [an abnormal heartbeat rhythm] uncontrolled hypertension or hypotension, history of postural hypotension, stroke, transient ischemic attacks [TIAs], etc), epilepsy, kidney and/or liver disease, glaucoma, alcohol or drug addition, eating disorders (anorexia nervosa, bulimia, etc.), pulmonary hypertension, pheochromocytoma, Tourettes syndrome, seizures, gall stones, etc.? If yes, please explain:	Yes No
Do you have any organic causes of obesity including hypothyroidism? If yes, please explain:	Yes No
Are you taking any, dietary supplements, laxatives, steroids, prescription medications including: weight loss medications (diethylpropion, phentermine, phendimetrazine, ephedra [ma huang], yohimbe. etc.), medications that can raise blood pressure such as decongestants (pseudoephedrine, phenylpropanolamine etc.), cough suppressants (dextromethorphan, pseudo ephedrine, etc.), MAO Inhibitors (Marplan [isocarboxazid], Nardil [phenelzine sulfate], Parnate [tranylcypromine], Eldepryl [selegiline hcl] Manerix ]moclobemide], etc.), tricyclic antidepressants Elavil [amitrypfiline], Lofepramine [methotrimeprazine], etc.), Selective Serotonin Re-uptake Inhibitors (SSRls) (Prozac [fluoxetine], Zoloft [sertraline], Effexor [venlafaxine hcl], Luvox [fluvoxamine maleate], Paxil [paroxetine hcl]), Zyban [bupropion hcl], Serzone [nefazodone],etc.), bipolar medication (Lithium Carb [lithium], etc.), epilepsy medications (Carbamazepine [carbamazepine]), Phenob [phenobarbital], Dilantin [phenytoin], etc.) Parkinson's disease (Larodopa [levodopa], Lodosyn [carbidopa],etc.), pain medications (Sublimaze [fentanyl], Elmiron [pentazocine], Touro DM [dextromethorphan], Demerol [meperidine], etc.), steroids (Gengraf [cyclosporin], Aeroseb-DEX [dexamethasone],etc.), anti fungal medication (Nizoral [ketoconazole]), antibiotics (ERY-Tab [erythromycin], Rifadin [rifampicin], Biaxin [clarithromycin], Nizoral (ketoconazole],etc.); migraine medications (Imitrex [sumatriptan], Migranal [dihydroergotamine]); antiinfectives (Furoxone [furazolidone], etc.) If yes, please explain:	Yes No
Are you pregnant, breast-feeding or planning to conceive? If yes, please explain:	Yes No
Do you have a history of hypertension (high blood pressure) If yes, what is you current blood pressure, how is the hypertension treated?	Yes No
I agree to monitor my blood pressure while taking this medication?	Yes No

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