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07425 899611

Weight Loss Tablets Consultation

Losing weight can be difficult and demotivating if your hard work isn’t being reflected on your bathroom scales. But losing weight and improving your health can significantly increase your quality of life. And this is especially true for people who are clinically obese.

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Please state your gender

This refers to your biological gender

Male

Female

What is your date of birth?

Use the calendar to select your date of birth.

Please add your height (in cms)

Your height is important for the prescribers decision.

Please add your current weight (in kgs)

Please make sure to add your current weight. This may affect the prescriber's decision.

Do you have any recent or past medical history of note?

If so, please provide more information

Yes

No

Do you suffer from any allergies?

If so, please provide more information

Yes

No

Do you currently take any medication whatsoever?

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

Yes

No

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

No

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

No

2. About your Condition

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Is this a repeat prescription?

Yes

No

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

Yes

No

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

Yes

No

Are you allergic to orlistat?

Yes

No

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
Surgery to remove your gall bladder (cholecystectomy)
Cholestasis (condition where the flow of bile from the liver is blocked)
any serious medical condition which may require immediate hospitalisation

Yes

No

Are you using an oral contraceptive?

Pleae Note: Orlistat can reduce the absorption of oral contraceptives and therefore reduce their effectiveness and increase the risk of their failure. You should use additional forms of contraceptive whilst taking orlistat.

Yes

No

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

Please Note: You must speak to your GP to discuss the dosage of your medicine when your weight changes.

Yes

No

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

If so, please list the medication

Yes

No

Are you taking any of the following medications?

Other Anti-Obesity Drugs
HIV Medication
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
Antidepressants
Antipsychotics including lithium
Benzodiazepines including diazepam

Yes

No

Do you understand that treatment cannot be continued if you gain weight 3 months after starting the treatment?

Yes

No

Do you understand that the treatment must be stopped once your BMI goes below 28?

Yes

No

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.

Yes

No

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 Orlistat (Xenical/Alli/Orlos) such as at bedtime.

Yes

No

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

No

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

0%

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will 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
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

No

I agree to the Terms and Conditions and I confirm that I am over 18.
Terms and Conditions

Yes

No

About Us

Profarma Direct is a cutting-edge online pharmacy that specialises in lifestyle medicine and personalised prescriptions.

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom
07425 899611
For Sales & Orders:
info@profarmadirect.com
For General Enquiry:
info@profarmadirect.com

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How to check GPhC Registration

You can check our pharmacy details and registration status here. You can also see details of any Fitness to Practise decisions relating to a registrant.

GPhC Registration Number:

2076639

GPhC Registered Owner:

Profarma Direct Ltd

Superintendent Pharmacist:

Zakaria Jalgaonkar

GPhC Pharmacy Details:

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom

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