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Consultation Questionnaire - Online

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All orders are dispatched within 24 hours of receipt. All orders are insured and delivery will take 5 to 10 days.

Medical Questionnaire
	Click here to select from metric measurements for height and weight
Height (ft):	---Please select height--- under 4ft 10in 4ft 10in 4ft 11in 5ft 5ft 1in 5ft 2in 5ft 3in 5ft 4in 5ft 5in 5ft 6in 5ft 7in 5ft 8in 5ft 9in 5ft 10in 5ft 11in 6ft 6ft 1in 6ft 2in 6ft 3in 6ft 4in 6ft 5in 6ft 6in Over 6ft 6in
Weight (lbs):	---Please select weight--- under 130 130 132 134 136 138 140 142 144 146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 190 200 210 220 230 240 260
Do you suffer or have you ever suffered from Anorexia Nervosa or Bulimia ?:	Yes No
Do you suffer from any Malabsorption Syndrome (eg Idiopathic Steatorrhoea or Tropical Sprue) ?:	Yes No
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 ?:	Yes No
Do you take the medicine Cyclosporine (Neoral, Sandimmune, SangCya)?:	Yes No
Do you suffer from the medical condition Cholestasis or any disorder of the gallbladder? Answer "No" if you have had your gallbladder removed:	Yes No
Known Allergies:
Please list all prescription and non-prescription ("over the counter") medications you are currently taking, even if only occasionally.
Do you have any medical conditions, particularly diabetes, or high cholesterol levels. If so please give details. If you are unsure, you should ask your regular doctor:
Do you consider anything else in your medical history to be relevant. Please give details:
If this is a repeat order, enter previous order number or enter promotional six digit number (if any) in this field.
Please select quantity:	4 weeks (84 capsules) US$99.00* 8 weeks (168 capsules) US$198.00* 12 weeks (252 capsules) US$297.00*

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