1. About your Health
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us .
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Please state your gender
This refers to your biological gender
Date of Birth
Use the calendar to select your date of birth.
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
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 know if your blood pressure is Low, Normal or High? Please write LOW, NORMAL or HIGH
Use the following as a guide:Low = Under 90/60Normal = Between 90/60 and 140/90High = Over 140/90
Do you smoke?
If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.
Do you drink alcohol?
If so, please tell us how many units per day. You can use the following as a guide:
Can you walk 3 miles or climb a set of stairs without pain in your chest?
If you cannot, please provide more information
Have you previously had a transient ischaemic attack (mini stroke) or stroke?
Do you suffer from any allergies?
If you do, kindly explain them below
Do you currently take any medication whatsoever?
Please list all your current prescription medication including any medication you buy over the counter.
Have you recently finished any course of medication?
Is there a history of medical disorder's within your family?
If so, please provide more information
Have you ever had any surgery (operations)?
If so, please provide more details
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2. About your Weight Loss
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us .
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Is this a repeat prescription?
Have you previously been on a course of any prescription treatments such as Reductil / Xenical / Acomplia or Phentermine?
Are you currently on a course of any prescription treatments such as Reductil / Xenical / Acomplia or Phentermine?
Are you taking any anti-depressive medication?
Do you have a current or previous history of depression, suicidal thoughts, generalised anxiety disorder or any other psychiatric disorder?
Women only: Are you pregnant or is there a possibility you may be pregnant?
If you are male, answer No
Women only: are you currently breast-feeding?
If you are male, answer No
Do you have a history of having an eating disorder?
Have you been told by a doctor that you have high cholesterol?
If yes, please provide more details
Have you been told by your doctor that you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucosegalactose malabsorption)?
If yes, please provide details
Are you currently taking any medicinal inhibitors e.g. ketoconazole / ritonavir / telitrhomycin / clarithromycin / nefazodon?
Have you informed your GP that you're taking this medication?
Have you tried to manage your weight by altering your diet and increasing physical activity?
Do you think there could be psychological causes for your problem e.g anxiety or depression?
Do you have a history of heart arrhythmias?
Do you have a history of congestive heart failure?
Do you have a history of peripheral arterial disease?
Do you have uncontrolled high blood pressure (hypertension) (e.g. > 145/90 mmHg)
Are you aware of any disease in your liver or kidney?
Can you think of any other health / medical details not mentioned above?
Is there anything else which you feel we should know about prior to you taking this medication?
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