Online Xanax Prescription Questionnaire

June 20, 2011

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?

Download Online Xanax Prescription Questionnaire in Word Format

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