* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Which Bitter Orange products were used?

Date you stopped taking this drug:

Date you started taking this drug:

Have you taken the diet drug Meridia?Yes
No

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

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:

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