Saturday, July 4, 2009  

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Xenical Data Sheet

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With this form you can purchase Xenical using your credit card.

The following information is needed by the doctor in order to safely prescribe Xenical.
 

Medical Questionnaire - Part 1 of 4
Date of Birth:
Click here to select from metric measurements for height and weight

Height (ft):
Weight (lb):
Select Sex
 Female Male
Do you suffer or have you ever suffered from Anorexia Nervosa, Binge Eating Disorder or Bulimia ?
 No Yes
Do you suffer from any Malabsorption Syndrome (eg Chron's Disease, Idiopathic Steatorrhoea or Tropical Sprue)? No Yes
You should not breastfeed your infant during treatment with Xenical as it is not known whether Xenical is secreted in human milk.
Are you currently breastfeeding, or do you intend to be doing so in the near future? 		No Yes
Do you take the medicine Cyclosporine (Neoral, Sandimmune, SangCya)? No Yes

Do you suffer from the medical condition Cholestasis or any disorder of the gallbladder? Answer "No" if you have had your gallbladder removed. 		No Yes
Do you suffer from Hypothyroidism?
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone.
 No Yes

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