Assessment

Please enter your date of birth

Height (feet)

Height (cm)

Have you taken or are you taking Xenical / Orlistat to help you lose weight?

Did Xenical help with your weight loss? Name any side effects experienced when taking the medication.

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?

Please give more details - list any medication you are taking.

Do you have any known allergies?

Please provide more information below.

Have you ever been diagnosed with any of the following:

• Chronic Malabsorption Syndrome? (problems with absorbing your food)
• Gallbladder, Bile duct or Pancreas disease
• Kidney condition
• Liver condition

Have you ever been diagnosed, or do you currently suffer with an eating disorder such as anorexia or bulimia?

Are you pregnant, planning to become pregnant or breastfeeding?

Are you currently taking any other prescription-only medication, alternative medication or recreational drugs?

Please provide more information below.

Do you understand that Orlistat will not work alone. for best results, this medication must be combined with a weight management plan, and regular exercise.

Do you understand that side effects (particularly oily stools), may be more likely if you have a high fat diet. fat should take up no more than 30% of your calorie intake.

Do you understand that you should stop taking this medication if your BMI drops below 28?

We strongly advise that you inform your GP of any medication you receive.

Would you like us to inform your GP of medication you receive from Rightdose?

Please enter your:

• Full Name
• Date of Birth
• Your registered home address with your GP

Please enter your:

• GP Surgery Name
• GP Surgery Address
• GP Surgery Email
• GP Surgery Contact Number

I confirm:

• I am over 18 years old.
• The medicine ordered is for my sole use only.
• I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• I have answered all the questions truthfully.
• I agree to the Rightdose online pharmacy privacy policy and terms and conditions.