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 MED INFO CENTER

FAQ

Admin

 XENICAL

 Medical History

 Your medical history will inform us of any possible medical contraindications to taking prescription medication, particularly Xenical.  This information is required before any physician intervention or treatment can be initiated.

 1.      I have had a thorough medical exam by a licensed physician within the last year:  (yes or no)

 2.      I agree that I will answer all questions accurately and truthfully in this medical history:  (yes or no)

 3.      Sex:  (male or female)

 4.      If female, have you had a regular menstrual period within the last 30 days?  (yes or no)  [for men, list not applicable].  If no, explain why not:

 5.      Height:

 6.      Current weight:

 7.      Date of birth:

 8.      Social security number:

 9.      Do you currently have any of the following symptoms or conditions:

         Gallstones   (yes or no)

    Bile stasis   (yes or no)

    Malabsorption syndromes   (yes or no)

   Are you bulimic?   (yes or no)

     Are you anorexic?   (yes or no)

     Are you currently a nursing mother?   (yes or no)

 Are you currently pregnant?   (yes or no)

 Are you currently taking any medication for immunosuppression, such as:  cyclosporine?   (yes or no)

     Are your weight and obesity problems caused by any organic nature, such as:  hypothyroidism?   (yes or no)

Xenical is indicated for obesity management, including weight loss and weight maintenance, when used in conjunction with a reduced calorie and fat diet.  In order to lose or maintain weight, caloric input and output must be in the proper ratio; meaning caloric output must be higher than caloric input.  When taking an obesity management drug such as Xenical it is recommended that your diet contains approximately 30 percent of its calories from fat and be nutritionally balanced.  You should also take a fat-soluable multivitamin / multimineral supplement each and every day.    

10.   I understand and agree to the above statement:  (yes or no)

The most common side effects from Xenical include, but are not limited to; excessive gas, increased frequency of stools, fecal urgency (i.e., the need to have a bowel movement), fecal incontinence, fatty and oily stools.  These adverse reactions were noted, but also should be noted that they were mild and passed with time.  The majority of these reactions lasted no more than four weeks and over 50 percent were resolved in less than seven days.

11.  I understand the possible side effects of Xenical:   (yes or no)

12.   Please list any over-the-counter or prescription medications you are currently taking.

13.   Are you allergic to any medications?  Please list below:

14.   Please list any additional comments regarding your general health that you think may be relevant:

WAIVER OF LIABILITY

[Text will be put in at a later date.]

PAYMENT INFORMATION

[This will include, but not be limited to;  payment type, name, credit card number, credit card expiration date, credit card billing address, city/state/zip code and country.  The exact format will have to be continued to be explored.]