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I hereby certify that I am at least eighteen years of age and will carefully read and truthfully answer all of the following questions:

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CVV2: (Card Verification Value) 0000000000000000	(required for credit card payment only) For your safety and security, individuals are now required to enter their credit card's verification number (CVV2 code). The verification number is a 3-digit number printed on the back of most credit cards, (the number appears after and to the right of your card number), please refer to the example. If using an American Express card the CVV2 code is a 4-digit number printed on the front of your card, please refer to the example. Please note: By providing the CVV2 code this helps to insure that the credit card is in the possession of the user helping to decrease fraudulent charges.

Billing Address: The next section addresses the actual billing address where the credit card statement is mailed each month. Please enter the exact address of where the credit card statement is sent each month for payment. This address will be verified with the issuing credit card company prior to charging the credit card. The billing address must exactly match the address on file where the credit card statement is mailed each month, or the charges will not be approved. This represents just another security measure taken to prevent fraudulent charges while maintaining our discount Reductil prices.
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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 28. (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 meters has a BMI score equal to 28 (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)
Weight:	2.2lb = 1kg (required)
Date of Birth:	(required) *Example: 07/02/79*
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Medical History: Please read the following very carefully. If you have any of the following medical conditions, please follow with an accurate explanation.
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
	000000000

Additional Medical Information: Please read the following very carefully. If you answer "yes" to any of the questions presented below, please follow with an accurate explanation.
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:	Yes No
	000000000

Reductil Specific Questions: Please read the following very carefully. If you answer "yes" to any of the questions presented below, please follow with an accurate explanation.
Currently, are you following any type of diet program or have you been on any diets in the past? If yes, please explain:	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 your blood pressure while taking this medication?	Yes No

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