Online Xanax Prescription Questionnaire


Online Xanax prescription questionnaire is a prescription prepared by various medical stores or pharmacy before giving this drug to an individual. Xanax is used as a treatment for anxiety disorders combined with depression. Therefore for purchasing this drug, one has to answer a questionnaire that would confirm his or her illness, as the prescription is unavailable to the sellers. Such a sample questionnaire has been provided below.

Sample Online Xanax Prescription Questionnaire

Name: __________________________________________________

Age: __________

Sex: ________

Please answer the questions given below in brief:

1)   What disorder are you suffering from?

_________________________________________________

2)   Since when are you suffering this disorder?

__________________________________________________

3)   Whom did you consult, at first, regarding your problems?

__________________________________________________

4)   Did you consult any other physician after that?

__________________________________________________

5)   If yes, how many other physicians did you consult?

__________________________________________________

6)   Who prescribed ‘Xanax’ to you?

___________________________________________________

7)   Have you taken ‘Xanax’ medication before this?

___________________________________________________

8)   If yes, for how long have you been taking this medication?

___________________________________________________

9)   Have you ever experienced side effects like hallucinations, slurred speech, increase in appetite, change in libido, ataxia, skin rash, symptoms of jaundice etc. after taking this drug?

________________________________________________________________________

10)               Have you consulted your physician regarding these side effects?

11)               Did he provide any other medication for your disorder?

______________________________________________________

12)               What is the prescribed dosage?

________________________________________

13)               Are you taking itroconazole or ketoconazole?

_________________________________________________

14)               Do you suffer from asthma, emphysema or any other breathing troubles?

_____________________________________________________________________

15)               Are you allergic to any other drug?

_________________________________________

16)               If yes, have you told your physician that you are allergic to those drugs or substances?

________________________________________________________________________

Category: Online Questionnaire

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