Weight Loss - Medical Assesment

If you have ordered this medication before, you can log in to fill up the questionnaire automatically. Our pharmacists have a few quick and easy questions to help issue your FREE online prescription

Weight Assessment
You must answer the question to continue
You must answer the question to continue

Your BMI

Your BMI is currently 0 and you are not eligible for treatment.

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

You must answer the question to continue
Health

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

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We are unable to supply you with orlistat. Please consult your GP.
 

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

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We are unable to supply you with orlistat. Please consult your GP.
 

Are you allergic to orlistat?

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We are unable to supply you with orlistat. Please consult your GP.
 

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
  • 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
You must answer the question to continue
We are unable to supply you with orlistat. Please consult your GP.
Medication

Are you using an oral contraceptive?

You must answer the question to continue
The use of an additional contraceptive method is recommended to prevent possible failure of oral contraception that could occur in case of severe diarrhoea.
 

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

You must answer the question to continue
You must speak to your GP to discuss the dosage of your medicine when your weight changes.
 

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

You must answer the question to continue
 

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
You must answer the question to continue
We are unable to supply you with treatment. Please consult your GP.
Agreement

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

You must answer the question to continue
We are unable to supply you with orlistat if you do not understand this. Call customer support for assistance.
 

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

You must answer the question to continue
We are unable to supply you with orlistat if you do not understand this. Call customer support for assistance.
 

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.

You must answer the question to continue
We are unable to supply you with orlistat if you do not understand this. Call customer support for assistance.
 

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.

You must answer the question to continue
We are unable to supply you with orlistat if you do not understand this. Call customer support for assistance.
 

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 must answer the question to continue
You must agree to this before continuing. If you need assistance contact customer support.
You must click on the terms and conditions to continue
01273 204 905

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hello@burwashmedsdirect.co.uk

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Mon – Fri 09:00 – 18:00

Saturday 09:00 – 13:00

Sunday Closed