* First Name 

   * Last Name 

   * Email 

   * Phone 

Cell Phone 

Date you started taking this drug:

Date you stopped taking this drug:

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:

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