Are you registered with a GP practice in the UK?
Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost
confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with
important information which will help them make an informed decision in deciding if the
treatment is considered to be suitable for you).
Do you believe you have the capacity to make decisions about your own healthcare?
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 breast feeding or intending to become pregnant or start breast feeding whilst taking medication?
Are you allergic to orlistat?
Have you been diagnosed with any of the following?
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)?
Are you taking any of the following medications?
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 to the following?