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Medical Assessment

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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:

Enter Your Weight:

Do you suffer from diabetes, heart disease, high blood pressure or high cholesterol?
 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?
We are unable to supply you with orlistat. Please consult your GP.
Please complete this question.
Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking medication?
We are unable to supply you with orlistat. Please consult your GP.
Please complete this question.
Have you been diagnosed with any of the following?
  • Problems absorbing food (chronic malabsorption syndrome) diagnosed by a prescriber
  • Liver problems
  • Kidney problems
  • Thyroid problems
  • Surgery to remove your gall bladder (cholecystectomy)
  • Cholestasis (condition where the flow of bile from the liver is blocked)
  • any serious medical condition which may require immediate hospitalisation
We are unable to supply you with orlistat. Please consult your GP.
Please complete this question.
Have you ever suffered from an eating disorder such as Anorexia Nervosa or Bulimia?
We are unable to supply you with orlistat. Please consult your GP.
Please complete this question.
Your Medication
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
  • Other Anti-Obesity Drugs
  • 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
  • a thyroid medicine (levothyroxine)
  • Iodine salts
  • Amiodarone, used for heart rhythm problems.
  • Acarbose (an anti-diabetic drug used to treat type 2 diabetes mellitus)
  • Anti-convulsant/anti-epileptic drugs
  • Antidepressants
  • Antipsychotics including lithium
  • Benzodiazepines including diazepam
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Are you taking any medicine for high cholesterol, diabetes or high blood pressure?
You must speak to your GP to discuss the dosage of your medicine when your weight changes.
Please complete this question.
Are you using an oral contraceptive?
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 contraceptive whilst taking orlistat.
Please complete this question.
Agreement
Do you understand that the treatment must be stopped once your BMI goes below 28?
We are unable to supply you with orlistat if you do not understand this. Call 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?
We are unable to supply you with orlistat if you do not understand this. Call 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 Xenical such as at bedtime.
We are unable to supply you with orlistat if you do not understand this. Call 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.
We are unable to supply you with orlistat if you do not understand this. Call 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, if you start new medication or if 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.
You must agree to this before continuing. If you need assistance contact customer support.
Please complete this question.
Complete our 2 minute questionnaire
We’re almost done!
Ana Carolina Osorio De Faria Goncalves
To find a treatment suitable for you, we just need you to answer a few questions.
Ana Carolina Goncalves
Superintendent Pharmacist
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Need help?

If you need help with this medical assessment, contact our helpline:

0207 112 9014

or email us:

help@pharmica.co.uk
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We are regulated by the General Pharmaceutical Council

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