THE DIENNET INSTITUTE
9454 Wilshire Boulevard Beverly Hills, CA 90212
(310) 277-3436 (800) 272-3436
Fax (310) 777-6989
www.diennet.com

THIS IS AN ONLINE CONSULTATION ON INTERNET.
 
 

QUESTIONNAIRE B

If the question does not apply, please do NOT answer.

 All information submitted is private and confidential!

DIENNET®ANALYTICAL QUESTIONNAIRE

The Diennet Slimming Program Questionnaire B Re-Order For Returning Patients

If you are a returning client then you know what to do! Just fill out the questionnaire below to the best of your ability to help us keep track of your progress.Thank you

Dr M Diennet M.D.

This is a Reorder, for those who have already been on the Diennet Program! Thank You.
All information submitted is private and confidential!
This is not an online pharmacy, patients must present proof of a yearly physical exam by a primary care physician with the correct blood test and Lab work. You will be contacted by telephone or E-mail after we have received your questionnaire.

Please See Below

QUESTIONNAIRE B

If You Would Like To Pay For A Rush Order (Receive Your Pills In Half The Time It Usually Takes!) Follow The Links Back To Diennet.com After Completing Your Credit Card Payment Form. Click Here To Pay Now

* Required Fields

*FIRST NAME
*LAST NAME: 
M.I.:
Street: 
City : 
State:
Zip/Country:
*Telephone: ( )  Home
Telephone: ( )  Work
Fax: ( )  Fax
*E-Mail: 

Your Profession


 
 
1. Nervousness
 
 

A. Are you more nervous on my program? Yes
B. Are you tired on my program? Yes
C. Are you outgoing on my program? Yes
D. Do you keep things bottled up on my program? Yes
E. Are you anxious on my program? Yes
F. Are you more depressed on my program? Yes
G. Do you cry often on my program?. Yes
H. Are you claustrophobic on my program? Yes
I. Do you sleep better on my program Yes
J. Do you have nightmares on my program? Yes
K. Do you take sleeping pills on my program Yes
L. Do you sleep too much on my program? Yes
M. Have you had sexual problems while on my program? Yes

Comments:


 

2.General

    A. Has your hearing improved on my program?
    Yes
    B. Has your vision improved on my program?
    Yes
    C. Are you sticking to the program?
    Yes
    D. Are you more constipated on my program?
    Yes
    E. Do you sleep less on my program?
    Yes
    F. Did you lose weight on my program?
    Yes

    Comments:

     

3.Digestion
 
A. Has your digestion improved on my program? Yes
B. Do you feel bloated after meals on my program? Yes
C. Do you ever have stomach aches on my program? Yes
D. Is your stomach ever distended with gas on my program? Yes
E. Do you have intestinal gas on my program? Yes
F. Do you have headaches on my program? Yes
G. Do you feel sick after eating or drinking on my program?  Yes
H. Do you suffer from any additional allergies on my program? Yes

Comments:


 

4. Medical Treatment:
 
A. Are you presently under any medical treatment? Yes
B. If yes, are you taking any of the following:
a. Antibiotics Yes 
b. Diuretics Yes 
c. Appetite suppressant Yes 
d. Cardiac medication Yes 
e. Cortisone medication Yes 
f. Thyroid medication Yes 
g. Hormone: Progesterone Yes 
h. Hormone: Estrogen Yes 
i. Other Medications Yes 
WHICH ONES? 

 
 

    5. Weight
     
    A. Have you reached your ideal weight?  No
    B. How many pounds did you lose?
    C. How much more do you want to lose?
    D. Do you want your weight to be stabilized? (you will not lose more) Yes

     
     

    6. What do you think of the program?
     
    = excellent 
    = good 
    = average 
    = poor 

     

By requirements of the FDA, please answer the following questions:
 
Is there any medication that you refuse to be in your prescription?  yes
If "yes", which one?

 

FOR THOSE WHO have been on the Diennet Program before and stopped.

    -If "yes", when did you stop? ........ 
    - Why did you stop?
    -Did you gain any weight back?............................ Yes 
    -How much?..................... . 
    -Why did you gain weight?

 

    -Do You Speak English? .............................. Yes ......................No

     

    Give us the name and the telephone number of the person who is translating for you.
    Full Name: ...........................................
    Telephone Number:......................
    I hereby certify that the above information is accurate and that I take the responsibility for following the whole program.
    I authorize the Diennet Institute to disclose all informations, including medical informations, to all physicians  whose names I have provided or may in the future provide to the Diennet Institute, to any physician who writes a prescription for me for any pills provided by the Diennet Pharmacy .
    I also authorize the Diennet Pharmacy and  any physician writing a prescription in order for me to receive these pills from the Diennet Pharmacy, to provide all informations, including medical informations, to the Diennet Institute and to doctor Marcel Diennet.
    I understand that medical and prescription informations will not be disclosed to any other party,except upon my authorization.
     

    Full Name:

    Date:

    Before submitting you should save as an html file and keep it for reference..

    The Diennet Institute 
    9454 Wilshire Boulevard # M 4 
    Beverly Hills, CA 90212 
    (800) 272-3436 /

    Fax (310) 277-7120

    If you have a personal question send e-mail to Dr. Marcel Diennet