Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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Weight Assessment

Please ensure you enter accurate height and weight details as this may affect future prescribing decisions

Enter your height:

cm	feet/inches

ft
in

Enter your weight:

kg	stones/pounds

st
lb

Your BMI:

Target weight loss in 3 months:

Your target weight in 3 months:

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

Yes

Your BMI is currently and you are not eligible for treatment.

Your BMI is currently and you are not eligible for treatment. We advise patients with BMI above 60.0 to contact our customer support or to consult their GP.

Your BMI is currently and has from since you have first ordered Orlistat. To continue using Orlistat you need to lose at least 5% of your weight and so we are unable to continue your treatment. We recommend you speak to your GP for other options to help with your weight loss management. Contact customer support for further information.

The height you have entered is either too short or too tall - if this height is correct please contact us.

You must enter a valid height and weight

Please complete the question

Your Health

Are you allergic to orlistat?

Yes

We are unable to supply you with weight loss treatment. Please consult your GP or doctor.

Please complete this question.

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

Yes

We are unable to supply you with weight loss treatment. Please consult your GP or doctor.

Please complete this question.

Have you been diagnosed with any of the following?

Problems absorbing food (chronic malabsorption syndrome) diagnosed by a GP
Liver problems
Kidney problems
Thyroid problems
Surgery to remove your gallbladder (cholecystectomy)
Cholestasis (condition where the flow of bile from the liver is blocked)
Any serious medical condition which may require immediate hospitalisation

Yes

We are unable to supply you with weight loss treatment. Please consult your GP or doctor.

Please complete this question.

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

Yes

We are unable to supply you with weight loss treatment. Please consult your GP or doctor.

Please complete this question.

Your Medication

Are you currently taking any over-the-counter or prescription medication or any recreational drugs?

Yes

Are you taking any of the following medications?

Other weight loss treatments
HIV medication
Fat-soluble vitamins
Oral anticoagulant drugs used to thin the blood such as Warfarin
Ciclosporin (used after organ transplants, for severe rheumatoid arthritis and some severe skin conditions)
Thyroid Medicine (levothyroxine)
Iodine salts
Amiodarone (used for heart rhythm problems)
Acarbose (an anti-diabetic drug used to treat type 2 diabetes mellitus)
Anticonvulsant/anti-epileptic drugs
Antidepressants
Antipsychotics including lithium
Benzodiazepines including diazepam

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

Please complete this question.

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

Yes

You must speak to your GP or doctor to discuss the dosage of your medicine when your weight changes.

Please complete this question.

Are you using an oral contraceptive?

Yes

Orlistat can reduce the absorption of oral contraceptives and therefore reduce their effectiveness and increase the risk of their failure. You should use additional forms of contraception whilst taking orlistat.

Please complete this question.

Agreement

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

Yes

We are unable to supply you with weight loss treatment. If you do not understand this, call our customer support for assistance.

Please complete this question.

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

Yes

We are unable to supply you with weight loss treatment. If you do not understand this, call our customer support for assistance.

Please complete this question.

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 Orlistat (Xenical/Alli/Orlos) such as at bedtime.

Yes

We are unable to supply you with weight loss treatment. If you do not understand this, call our customer support for assistance.

Please complete this question.

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.

Yes

We are unable to supply you with weight loss treatment. If you do not understand this, call our customer support for assistance.

Please complete this question.

Do you agree to 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, you start new medication and/or your medical conditions change during treatment
The treatment is solely for your own use
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
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

Please complete this question.

Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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