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PROPECIAŽ
MEDICAL QUESTIONNAIRE
The following medical history
will assist our physician in deciding whether PropeciaŽ
is appropriate for your condition. All information
provided will remain secure, confidential and subject
to all patient/physician privilege laws. Please
take a few minutes to fill in the following information
as thoroughly and accurately as possible.
Personal
Information
Please fill in all fields. Failure
to do so will delay your order processing. ALL
must be completed to submit form
*Please
verify these spaces, errors may result in significant
delays.
Do
you have any known drug allergies?
If
yes, please list in the box provided:
Are
you currently taking any prescription and/or over
the counter medication?
If
yes, please list
Do
you use tobacco products?
If
yes, please quantify type of product and usage
Do
you consume alcohol?
If
yes, please quantify type of product and usage
Do
you currently follow a routine exercise program?
If
yes, please quantify type and amount of exercise
Do
you have any of the following medical conditions?
| Angina |
Hypotension |
| Arrhythmia
|
Kidney
Disease |
| Atherosclerosis |
Liver
Disease |
| Benign
Prostatic Hypertrophy |
Thyroid
Disease |
| Prostatic
Cancer |
Low
Testosterone |
| Blood
Disorders |
Neurological
Complications |
| Congestive
Heart Failure |
Psychiatric
Disorders |
| Diabetes |
Rheumatological
Complications |
| Endocrine
Disorders |
Stroke |
| Erectile
Dysfunction |
Valvular
Heart Disease |
| Hypertension |
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Do
you have any of the above medical conditions?
If
yes, please explain
Do
you have a history of any other medical condition?
If
yes, please explain:
Have
you had any surgeries in the past five (5) years?
If
yes please explain
Do
you currently believe you are experiencing hair
loss?
If
yes, please explain
How
old were you when you first noticed that your hair
was thinning?
Please
explain
Is
the hair thinning on the top of your scalp and/or
is your hair line receding?
If
yes, please explain
Was
your hair loss gradual?
If
yes, please explain
Was
your hair loss sudden?
If
yes, please explain
Does
male pattern hair loss run in your family?
If
yes, please explain
Have
you ever been treated for hair loss before?
If
yes, please explain what type of treatment
Have
you taken Propecia previously?
If
yes, please explain
PropeciaŽ
can effect a blood test called prostatic specific
antigen (PSA) for the screening of prostate cancer.
It is very important if you have a PSA test done,
to inform your physician that you are taking PropeciaŽ.
Specifically, do you currently plan to have a PSA
blood test for the screening of prostatic cancer
in the near future?
If
yes, please explain
Have
you ever experienced any difficulty with you liver?
If
yes, please explain
Note: There is no correlation between taking PropeciaŽ
and prostate cancer.
You have completed the Medical Questionnaire!
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PropeciaŽ
Pills
International orders are $46
to ship. If you choose to ship your order
outside the U.S., you are assuming all liability
for any customs, duties or tariffs. If for
some unforeseen reason your order is seized
by Customs, we are unable to refund your
money. By selecting International shipping,
you are agreeing with these terms. Note:
International orders please add an additional
$28.00 to the above totals (difference between
$46.00 - $18.00).
Secure
Ordering Process
Click on the
image for more info |
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*Please
verify these spaces, errors may result in
significant delays.
Please enter special instructions.
How
did you hear about us?
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By submitting this consultation form:
- I
certify that I am 18 years of age or older
- I
have read and agree to the Waiver of Liability
- I understand all the side effects of PropeciaŽ
- I
do not have a current prescription for PropeciaŽ
from another physician
- I
certify that I am allowed by law to use the credit
card I have presented
- I
understand that falsifying information in order
to obtain prescription medication is a violation
of both state and federal law
- If
outside the U.S. or Canada, I agree that I am
responsible for ALL import charges, tariffs, and
duties.
- If
outside the U.S. or Canada, my order is confiscated,
I accept full responsibility for the loss and
shall make no claim to my credit provider for
non-delivery, provided always that www.lifestylemeds.com
provides proof the order was shipped.
- I
hereby certify that I have answered all questions
truthfully
Please review all information
before submitting form so that your order will not
be delayed.
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