Diet Drug Registry
Please fill out all fields, then press the Submit button.

Which weight loss drugs did you take, and how long?
(check all that apply)

Who prescribed the drug(s)?
(pick one and fill in name of prescriber)

Did you have any health problems when the drug(s) were prescribed?
(check all that apply)

Did you suffer any side effects AFTER taking the drug(s)?
(check all that apply)

Have you been tested for health problems related to taking the drugs?

Yes No

If not, would you like to be tested?

Yes No

Would you be willing to speak to a NAAFA representative about your experiences with the drugs?

Yes No

Personal data:

Gender: Female Male

Age: Under 20 21-35 36-50 51-65 over 65

State: Zip:

What was your weight (in US pounds) before taking the drugs:

Comments (if any)