Appetite Suppressant Information
This is a confidential record and will be kept in your chart only. 
Information will not be released without your authorization.

The appetite suppressants that we prescribe are Phentermine and Phendimetrazine.  Both are FDA approved for the
treatment of obesity.  Please initial below to state that you will adhere to the following:

____        I will not take my appetite suppressant with any other diet medication (prescribed or not prescribed).  If I have questions about taking other supplements, I will bring them up at my next appointment before taking them.

____        I will not take my appetite suppressant with alcohol.

____        I will only take my appetite suppressants as prescribed.  I will not stop or start appetite suppressants or any other medication without notifying my provider at Derby Derm about it first.

____        I have not taken an MAOI within the last 14 days.  This is a contraindication of taking an appetite suppressant.

____        I will notify Derby Derm if I have any of the following (Does not necessarily disqualify the use of appetite suppressants):

*        An allergy to any type of stimulant.                        
*        Heart disease.
*        Severe high blood pressure.                                 
*        Arteriosclerosis.
*        A thyroid disorder.
*        Diabetes.
*        A Seizure disorder.

____        I will not take medication within 5 hours of sleeping.

____        If I miss a dose, I will not double my next dose.  I will simply skip that dose.

____        I will not share my appetite suppressants with any friends or family members.

____        I will come in weekly for my follow-up visits.  If there are any conflicts with this, I will let Derby Derm know as soon as possible.

____        The following is a list of possible side effects.  I am aware of these side effects and I will let my provider at Derby Derm know of any side effects I might have.

• These side effects include: Insomnia, headache, hair thinning, dry mouth, muscle cramps, constipation, hypertension, extreme nervousness, confusion, blurred vision, dizziness or skin rash or itching.   
  
• Some very rare side effects are: Convulsions, dizziness, fever, hallucinations, arrhythmia, hostility, irregular blood pressure, lightheadedness, mania or depression, shaking, panic, restlessness, stomach pain, diarrhea, nausea, vomiting or stomach pain.
  

• Headache - Aspirin, ibuprofen or other over the counter pain relievers.  (Excedrin is not recommended due to the fact it has caffeine in it).
  
• Hair thinning - Biotin 5g/day

• Dry mouth-lots of liquids and sugar free gum.
  
• Muscle cramps - potassium
  
• Sleeplessness -Tylenol PM
  
• Constipation - Daily fiber supplementation.  If needed, use a stool softener or mild laxative such as Miralax or milk of magnesia.  
  

• The patient must demonstrate consistent weight loss of 5% of body weight every 90 days.
  
• The patient must have no negative side effects from the medication.
  
• The patient must be seen regularly (on a weekly basis) by our medical staff to monitor these criteria.
  
  

Patient Information _____________________________________________________________________