| Please ensure you read through and understand the prescription form below prior to ordering |
| 1. I agree not to take this medication if I have a history of high blood pressure. |
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I Agree |
I DISAGREE If you disagree, please explain why: |
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2. I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking this medication immediately |
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I Agree |
I DISAGREE If you disagree, please explain why: |
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| 3. I agree not to take this medication if my Body Mass Index (BMI) is below 25. |
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I Agree |
I DISAGREE If you disagree, please explain why: |
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4. I agree not to take any over-the-counter medicines without approval from my pharmacist. |
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I Agree |
I DISAGREE If you disagree, please explain why: |
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5. I agree not to take this medication if I am pregnant, breast-feeding, or trying to get pregnant. |
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I Agree |
I DISAGREE If you disagree, please explain why: |
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| 6. Do you have any current medical conditions? If Yes, please specify. |
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Yes |
None |
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7. Is there anything in your medical history that you consider to be relevant? If Yes, please specify. |
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Yes |
No |
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8. Are you taking any over-the-counter and prescription medications? If yes then please list them with the length of time you have been taking each one. |
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Yes |
None |
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9. Are you planning to take any other medications while on this program? If yes please specify |
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Yes |
No |
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10. Do you suffer from any allergies? If yes - please list all past or present allergies including allergies to any medications. |
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Yes |
None |
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11. Have you had any surgery? If Yes - please list all past surgeries and provide details including the condition that was treated with each surgery. |
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Yes |
None |
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12. Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. This cannot be left blank. |
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