Title
Mr. Mrs. Ms. Miss Mr. & Mrs. Dr.

* First Name

* Last Name

* Email Address

* Phone Number

Cell Phone Number

Office Phone Number

Street Address

Apartment/Suite

City

State
-Choose State- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming -Puerto Rico- -U.S. Virgin Islands- -Other-

Zip Code

Please provide the best method and times to contact you:

Date of birth of person injured
(mm-dd-yyyy):

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

Which of the following were taken?
Metabolife 356
Xenadrine
Ripped Fuel
Ultimate Orange
Hydroxycut
Trim Spa
Other

Approximate number of servings taken:
Select 1-20 20-50 50-80 80-120 More than 120

Have you taken the diet drug Meridia?
Yes
No

Products obtained from:
Select Gym Store Physician Personal trainer Mail order Internet Other

Have any of the following occurred? (Please check all that apply.)
Cardiac death
Hemorrhagic stroke
Heart attack
Seizures
Cardiac arrythmia

Please further describe side effects:

Other Info:

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