Free Evaluation

Please fill out completely. If you do not know put unknown. If the question(s) is not applicable to you put n/a. Where directed, please list address, zip code, and phone #.

NOTE: An Asterisk (*) Indicates REQUIRED Information.

I. Personal Information

*First Name

*Last Name

Middle Initial

Present Street Address

Address (cont.)

City

State

Zip/Postal Code

Work Phone

Home Phone

FAX

*E-mail

URL

Date of Birth

Sex

Male Female

Social Security Number

Have you ever filed a lawsuit or made a claim, other than in the present suit, relating to any bodily injury?

If so, state the court in which such action was filed and the civil action or docket number assigned to each such claim, action or suit:

II. Current Medical Condition

Do you Currently suffer from any Physical injuries, illnesses or disabilities?

If so, please state the following:

Identify the injury, illness or disability and the date of onset:

Physician's name (whom first diagnosed injury, illness or disability) and address:

III. Current Medical Condition

Height: feet inches

Weight before use of Pondimin, Redux or Phentermine:

Current Weight:

Have you used prescription medications (other than Pondimin, Redux, or Phentermine), herbal preparations, or over the counter products to control or reduce your weight:

If yes what products and approximate dates of use:

To the best of your knowledge, have you ever been told by a doctor that you have, or have had any of the following:

Hypertension or high blood pressure
Heart murmur
Heart attack
Stroke
Blood clot to the lung (pulmonary embolism)
Blood clot in the leg and/or phlebitis
Chronic lung disease
Congenital Abnormality of heart
Congenital abnormality of lungs/thorax/diaphragm
Primary pulmonary hypertension
Heart valve lesions
Heart valve prolapsed regurgitation
Other heart or lung disease

To the best of your knowledge, state whether any of the following tests were administered BEFORE your use of Pondimin, Redux and/or Phentermine and After

	BEFORE	AFTER
Echocardiogram (ultrasound of the heart)
Heart Catheterization
Pulmonary function test
Perfusion lung scan
Chest X-ray

IV. Diet Drugs

Please complete the following chart with respect to each diet medication you have taken:

Drug Name Generic/Brand Description: Color / Shape / Writing / Name	Approx. Date of First Taken	Approx. Date of Last Taken	County of Residence Where Drug Ingested
Redux/ Dexfenfluramine 15 mg. Capsule; white cap with black strip: Redux
Fenfluramine/ Pondimin Orange round tablet 20 mg.
Phentermine 1
Phentermine 2

Did you lose weight while on Pondimin, Redux or Phentermine?

State your High and low weight over the past ten years:

High: lbs.

Approximate Date:

Low: lbs.

Approximate Date:

IV. Diet Drugs

Do you claim that you have suffered bodily injury as the result - us of Pondimin Fenfluramine, Redux (dexfenfluramine) or Phentermine?

If the answer to the forgoing questions is "Yes" state the nature of the injury or injuries which you claim

Have you had discussions with any doctor about whether your condition is related to the use of diet drugs

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