Weight Loss

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

Kindly share your weight and height
Height should be above 1 ft 10 inches

What is your ideal weight?
Please tell us in Kg's or Stone

Have you ever tried to lose weight solely by food and exercise?
Do you require assistance?

Yes

No

Do you have a history of having an eating disorder?

Yes

No

Is Orlistat (also known as Xenical or Alli) anything you're taking right now?
If yes, what's the length of time you've been taking them?
Are you still shedding pounds?

Yes

No

Do you use any of the medications listed below?
Blood-thinning medications (such as warfarin).
Acarbose is a kind of sugar (to treat diabetes).
Ciclosporin is a kind of antibiotic (to prevent organ rejection).
Lithium is a kind of lithium (for mental health problems).
Amiodarone is a kind of amiodarone that is (for heart problems).
Medicines for the treatment of epilepsy and seizures.
Antiretroviral drugs (ARVs) are drugs that are used to treat HIV
Medicines for the treatment of psychosis and other mental illnesses.

Yes

No

Do you use levothyroxine (a drug used to treat low thyroid levels)?
If you do, what is your current dose and when was your latest thyroid blood test?

Yes

No

Did you know that while on Orlistat, you should:
For the best results, you must commit to a calorie-controlled, healthy diet combined with exercise.
To avoid side effects, keep your fat intake to less than 15 grams per meal.
You do not need to take a dose if you skip a meal or eat one that is low in fat.
Before going to bed, take a multivitamin supplement with vitamins D, E, and K.
It is suggested that you use a supplementary contraceptive technique if you take the contraceptive pill, especially if you have diarrhoea.
If you have not lost weight after three months of treatment or if your BMI falls below 27, your treatment may be stopped.

Yes

No

Does any of the following statements apply to you:
Orlistat causes an allergic reaction or hypersensitivity in you.
You've previously used Orlistat and experienced serious side effects.
You are experiencing rectal bleeding.
You have chronic malabsorption syndrome, which has been identified by a doctor.
You have been diagnosed with cholestasis (condition where the flow of bile from the liver is blocked)

Yes

No

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

No

Have you received advice from a weight management counsellor before?

Yes

No

Have you tried to manage your weight by altering your diet and increasing physical activity?

Yes

No

Do you have a medical history of any of the following listed below?
Diabetic gastroparesis; Inflammatory bowel disease; Ketoacidosis; Congestive heart failure; Severe renal impairment; Severe hepatic impairment; Thyroid disease; Pancreatitis.

Yes

No

Would you object to a low-calorie diet as part of treatment?

Yes

No

Has a low-calorie diet failed to manage your weight in the past?

Yes

No

Do you currently have, or have a history of pancreatitis?
If yes, please provide details

Yes

No

Do you have any of the following listed below?
Dysglycaemia; Hypertension; Dyslipidaemia; Obstructive sleep apnoea.

Yes

No

Do you know your Body Max Index?
If yes, please list it below

Yes

No

Have you had a serious reaction to Saxenda before?

Yes

No

Are you currently using any weight management products?

Yes

No

Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Yes

No

Do you have inflammatory bowel disease (ulcerative colitis, crohn's disease etc.)?

Yes

No

Do you have any endocrinological disorders or eating disorders?
If yes, please provide details

Yes

No

Do you have diabetes?

Yes

No

Do you have any liver, kidney or heart problems?
If yes, please provide details

Yes

No

Do you have any allergies?
If yes, please provide details

Yes

No

Women only: Are you breast feeding?

Yes

No

Please list all your current prescription medication including any medication you buy over the counter...

All Conditions

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