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1. 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.*

2. Is your current physician aware of your ordering of this medication?*
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3. How often do you take this medication?*

4. Do you have allergies?*
YES (Specify Allergies) NO

5. Do you have any active medical conditions or comorbidities? *
YES (state existing conditions or comorbidities) NO

6. Do you have any past medical and psychiatric conditions including any surgery or other procedures?*
YES (state past medical and psychiatric conditions) NO

7. Are you taking any other medications? If yes, please list all prescription and over-the-counter medications that you are currently taking and the length of time for each.*
YES (specify other medications and length of time) NO

8. Do you smoke or consume alcohol in excessive amounts? (Yes or No)*
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9. (If your gender is female please answer the question. Otherwise type "none") Are you currently or within the last 12 months been pregnant or nursing? Do you plan on getting pregnant soon?*

10. Do you have a condition called Porphyria?*

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*Medical Disclaimer: Always consult your physician before purchasing this medication.

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