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  2. Weight Loss
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1. Assessment Form
2. Choose Treatment
3. Your Order
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Medical Assesment Weight Loss

About You

Are you registered with a GP practice in the UK?

This field is required.

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.)

This field is required.

Do you believe you have the capacity to make decisions about your own healthcare?

This field is required.
You must have the capacity to make decisions about your own healthcare to proceed. Please see your GP
Symtoms

What is your target weight in kg?

This field is required.

Have you previously tried to lose weight by diet and exercise alone?

This field is required.

Have you ever suffered from an eating disorder?

This field is required.
Health

Do you have type 1 or type 2 diabetes?

This field is required.
This medication is not suitable for you. Please consult your GP.

Are you currently taking Orlistat (also known as Xenical or Alli)?

  • How long have you been taking them for?
  • Are you still losing weight?
This field is required.

Do you take any of the following medicines:

  • Medicines that thin the blood (such as warfarin).
  • Acarbose (to treat diabetes).
  • Ciclosporin (to prevent organ rejection).
  • Lithium (for mental health problems).
  • Amiodarone (for heart problems).
  • Medicines to treat epilepsy or seizures.
  • Levothyroxine (to treat low thyroid levels).
  • Medicines to treat HIV.
  • Medicines to treat psychosis or other mental health issues.
This field is required.

What is your height in cm?

This field is required.

What is your weight in kg?

This field is required.

What is your BMI?

This field is required.

Do you smoke

This field is required.

Do you drink alcohol

This field is required.

Are you pregnant or breastfeeding?

This field is required.

Do any of the following apply:

  • You suffer with any medical conditions that you have not already mentioned
  • You have had major surgery
  • You have allergies
  • You have heart problems or have had a stroke
  • You have decreased kidney or liver function
This field is required.

What is your blood pressure?

Select the most appropriate answer:




This field is required.

Do you suffer with thyroid problems?

This field is required.

Are you aware if you take the contraceptive pill, it is recommended that you use an additional contraceptive method, especially if you suffer from diarrhoea:

This field is required.
Medication

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

This field is required.

Are you aware you need to commit to a calorie-controlled healthy diet combined with exercise for best results:

This field is required.

Are you aware if you skip a meal, or consume one with no fat content, you do not need to take a dose:

This field is required.

Are you aware you should take a multivitamin supplement containing vitamins A, D, E & K before bedtime

This field is required.

Are you aware treatment should not be continued if you have not lost weight after 3 months of treatment or if your BMI drops below 27.

This field is required.
Agreement
  • I confirm I am over 18 years old.
  • The medicine ordered is for my sole use only.
  • I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
  • 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.
  • I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
  • 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 are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.
This field is required.
You must click on the terms and conditions to continue
The decision about the treatment offered is for both the prescriber and patient to jointly consider. However, the final decision will always lie with the prescriber which will ensure patient safety is not compromised. If treatment is refused, you will be signposted to another service and given a full refund.