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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.
  
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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)?
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Currently, are you taking any medications (this includes over-the-counter or nonprescription medication, herbal supplements, sports supplements, etc.)
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Do you currently follow a routine exercise program?
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Reductil Specific Questions:
Please read the following list of medical questions carefully. Be sure to give any explanations if your answer is "yes" to any of the following.
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:
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Do you have any organic causes of obesity including hypothyroidism?
If yes, please explain:
 Yes
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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
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