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