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MEDICAL ASSESSMENT

Q No.QuestionAnswer
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/

2

Do you have high blood pressure, high cholesterol, lipids or diabetes?

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.

4

I understand that treatment with Xenical (Orlistat) cannot be continued if I gain weight.

5

I understand that treatment with Xenical (Orlistat) must be stopped once my BMI goes below 28.

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).

7

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

8

Are you taking any medicine for high cholesterol and/or diabetes?

9

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

10

Are you allergic to Xenical (Orlistat)?

11

Are you using an oral contraceptive?

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)

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

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

15

What is the name of your GP surgery and do you consent to us contacting them about your treatment?

16

Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability.

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