| 1 | Do you have a Body Mass Index (BMI) of 28 or above? Please check the link below https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/
You must answer this question. You must answer this question. | |
| 2 | Do you have high blood pressure, high cholesterol, lipids or diabetes?
You must answer this question. You must answer this question. | |
| 3 | I understand I must lose my target loss of 5% of my body weight after 12 weeks of starting treatment with Xenical (Orlistat) to be eligible to continue treatment.
You must answer this question. You must answer this question. | |
| 4 | I understand that treatment with Xenical (Orlistat) cannot be continued if I gain weight.
You must answer this question. You must answer this question. | |
| 5 | I understand that treatment with Xenical (Orlistat) must be stopped once my BMI goes below 28.
You must answer this question. You must answer this question. | |
| 6 | I understand Xenical (Orlistat) should be taken with a well-balanced, calorie controlled diet that is rich in fruit and vegetables and contains an average of 30% of the calories from fat. I am aware many prescribers recommend a good quality multivitamin to be taken at least two hours after taking Xenical (Orlistat).
You must answer this question. You must answer this question. | |
| 7 | Have you ever suffered from an eating disorder such as Anorexia Nervosa or Bulimia Nervosa?
You must answer this question. You must answer this question. | |
| 8 | Are you taking any medicine for high cholesterol and/or diabetes?
You must answer this question. You must answer this question. | |
| 9 | Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication?
You must answer this question. You must answer this question. | |
| 10 | Are you allergic to Xenical (Orlistat)?
You must answer this question. You must answer this question. | |
| 11 | Are you using an oral contraceptive?
You must answer this question. You must answer this question. | |
| 12 | Have you been diagnosed with any of the following?
• Chronic malabsorption syndrome (insufficient absorption of nutrients from alimentary tract)
• Liver problems
• Kidney problems
• Thyroid problems
• Cholestasis (a rare liver disorder)
You must answer this question. You must answer this question. | |
| 13 | Are you taking any of the following medications?
• Anticoagulant drugs such as warfarin (Athrombin, Athrombin-K, Coumadin, Jantoven, Panwarfin, Warfarin Sodium)
• Ciclosporin
• Levothyroxine (Levo-T, Levolet, Levothyroid, Levothyroxine Sodium, Levoxyl, Novothyrox, Synthroid, Tirosint, Unithroid)
• Iodine salts
• Amiodarone
• Acarbose (an anti-diabetic drug used to treat type 2 diabetes mellitus)
• Anti-convulsivant/anti-epileptic drugs
You must answer this question. You must answer this question. | |
| 14 | Do you agree to the following?
• You will seek medical attention if you experience any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
You must answer this question. You must answer this question. | |
| 15 | What is the name of your GP surgery and do you consent to us contacting them about your treatment?
You must answer this question. You must answer this question. | |
