Weight Loss Questions

Your Current Health

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 allergic to Orlistat

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
  • Cholestasis (condition where the flow of bile from the liver is blocked)
  • any serious medical condition which may require immediate hospitalisation

Are you using an oral contraceptive?

Are you taking any of the following medications?

  • Other Anti-Obesity Drugs
  • 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

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

Do you or have you suffered from any heart problems stroke, angina or any other heart related problems ?

Are you taking any medication that has been prescribed by your Gp/Doctor or Hospital ?

Do you give consent for us to contact you GP if required? (we need this to process any order for medication)


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 statements?

  • You must read the patient information leaflet supplied with your medication
  • You must 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 only.
  • You have answered all the questions in this short medical assessment accurately and truthfully to the best of your knowledge. You understand our doctor take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
all of our tests and treatments are price competative

You need to complete our short medical questionnaire so we can ensure the treatment you have selected is safe for you to use

all of our tests and treatments are price competative

Need Help?

If you need help with this medical questionnnaire call us on 07549286701

quality products assured across youth revisited

Quality products

all of our tests and treatments are price competative

Affordable prices

all of our pharmacies and and treatments purchased are from well known and trusted UK pharmacies

UK pharmacy

all of our tests and any other products purchased will be dispatched for a next day service

Express next day delivery

If you have any further questions about any of our products please feel free to contact us and we will do our best to help you.
Once you have your prescription we will be able to process your order through our trusted UK Pharmacy.