PATIENT INTAKE FORM

Patient Registration:


Medical History:

Have you ever had any of the following? (Check Boxes that Apply):
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimen, Adipex, Fasti (brand names of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine).
Are you under the care of a physician?
(Women) Do you suspect that you are pregnant?
(Women) Are you nursing?
(Women) Taking birth control pills?

PATIENT INTAKE FORM

Patient Registration:


Medical History:

Have you ever had any of the following? (Check Boxes that Apply):
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimen, Adipex, Fasti (brand names of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine).
Are you under the care of a physician?
(Women) Do you suspect that you are pregnant?
(Women) Are you nursing?
(Women) Taking birth control pills?