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Weight Assesment

Please enter your height:
Height: m
Please enter your weight:
Weight: kg
BMI:

YOUR HEALTH

Do you suffer from diabetes, heart disease, high blood pressure or high cholesterol?

Have you ever suffered from an eating disorder such as Anorexia Nervosa or Bulimia?

Are you pregnant or breastfeeding or intending to become pregnant or start breastfeeding whilst taking medication?

Are you allergic to orlistat?

Have you been diagnosed with any of the following?

  • Problems absorbing food (chronic malabsorption syndrome) diagnosed by a doctor
  • Liver problems
  • Kidney problems
  • Thyroid problems
  • Cholestasis (condition where the flow of bile from the liver is blocked)
  • any serious medical condition which may require immediate hospitalisation

YOUR MEDICATION

Are you using an oral contraceptive?

Are you taking any medicine for high cholesterol, diabetes or high blood pressure?

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

AGREEMENT

Do you understand that treatment cannot be continued if you gain weight 3 months after starting the treatment?

Do you understand that the treatment must be stopped once your BMI goes below 28?

Do you understand the treatment should be taken with a nutritionally balanced, calorie controlled diet that contains approximately 30% of the calories from fat? It is recommended that your diet is rich in fruit and vegetables.

Do you understand that you should take a multivitamin that contains vitamins D, E, and K and beta-carotene? It should be taken once a day at least 2 hours before or after taking Xenical(orlistat) such as at bedtime.

Do you agree with the following?

  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start a new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use
  • You give permission to access you NHS Summary Care Record in order to identify you correctly, check your medical history and provide the best possible care.
  • You give permission to contact your GP to inform them of your treatment.
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
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