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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

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