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Assessment Progress

1About you
2Treatment Preference
3Your Health
4Acknowledgements

NHS Prescriptions made Simple

We will arrange everything, from requesting your prescription from your GP, to arranging free delivery direct to your door.

Assessment

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1About you

Patient Notice! This questionnaire forms the basis of your weight loss consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medicinal information provided before selecting your treatment.

Please provide your age *

So we can calculate your BMI, please enter your height and weight (your weight measurement must be from the last week) *

Height (cm) *

Please ensure you enter your correct height as this can't be changed for future orders

Weight (kg) *

Height (feet) *

Weight (stone/pounds) *

BMI

Do you have any weight-related conditions such as high blood pressure, diabetes, obstructive sleep apnoea, or high cholesterol? *

NoYes

Please provide more information below: *

2Treatment Preference

Would you prefer treatment with weight loss tablets or weight loss injections? *

Saxenda is used as a weight loss aid for the following patients

patients with a BMI over 30
patients with a BMI over 27 with either
- diabetes
- high blood pressure
- high cholesterol
- sleep apnoea

Please use the NHS BMI calculator to check your BMI.

Weight Loss tablets such as Orlistat and Xenical, are used as a weight loss aid for the following patients

patients with a BMI over 30
patients with a BMI over 27 with either
- diabetes
- high blood pressure
- high cholesterol
- sleep apnoea

Please use the NHS BMI calculator to check your BMI.

3Your Health

Are you aged between 18-74? *

NoYes

Are you aged between 18 - 65? *

NoYes

Are you currently taking Xenical / Orlistat? *

NoYes

Where were you prescribed Xenical / Orlistat before? (E.g. private GP, different online pharmacy) *

Has Xenical / Orlistat helped with your weight loss? Please describe any side effects you have experienced from taking this medicine *

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

NoYes

Please give more details. List any medication you are taking. *

Have you ever been diagnosed with chronic malabsorption syndrome? (problems with absorbing your food) *

NoYes

Please provide more information *

Do you have any history of kidney or liver conditions? *

NoYes

Please provide more information *

Have you ever been diagnosed with gallbladder, bile duct or pancreas disease? *

NoYes

Please provide more information *

Are you currently taking Saxenda? *

NoYes

Where were you prescribed Saxenda before? (E.g. private GP, different online pharmacy) *

To aid our doctors in their prescribing decision, please provide details as to when this medication was first used and how long you have been using it for? *

Please also provide details of how much weight you have lost and if you experienced any issues or side effects? *

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

NoYes

Please provide more details *

Are you taking any of the following medication? *

Please ensure regular GP reviews with regards to thyroid disease and medication doses

Have you have had a risk assessment with your GP and had approval from your GP that you can use Saxenda and insulin at the same time? *

NoYes

Do you have any known allergies? *

NoYes

Please provide more details *

Symptoms of a serious allergic reaction may include: swelling of your face, lips, tongue, or throat, fainting or feeling dizzy, very rapid heartbeat, problems breathing or swallowing, and severe rash or itching.

Do you have any history of kidney or liver conditions? *

NoYes

Please provide more details (Saxenda is not safe for people who have a GFR below 30) *

Have you ever been diagnosed with congestive heart failure? *

NoYes

Please provide more details *

Have you ever been diagnosed with ulcerative colitis, Crohn’s disease or diabetic gastroparesis? *

NoYes

Please provide more details *

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

NoYes

Please provide more details *

Do you have any problems with your pancreas, or have you had any problems with your pancreas in the past? *

NoYes

Please provide more information below: *

Do you or anyone in your family have a history of thyroid cancer, medullary thyroid carcinoma (MTC), or an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)? *

NoYes

Please provide more information below: *

Are you pregnant, planning to become pregnant or breastfeeding? *

NoYes

Please provide more details *

Please provide how many calories you consume on a daily basis? *

How much exercise do you undertake per week? *

4Acknowledgements

I confirm I am aware Saxenda must be administered by using the following method.

Inject your dose of Saxenda® under the skin (subcutaneous injection) in your stomach area (abdomen), upper leg (thigh), or upper arm, as instructed by your health care provider. Do not inject into a vein or muscle
Never share your Saxenda® pen or needles with another person. You may give an infection to them, or get an infection from them

Confirm

You will store Saxenda in a refrigerator (2°C to 8°C) on receipt of delivery. If you do not do this, Simple Online Pharmacy cannot be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C or in a refrigerator. *

Confirm

Whilst using Saxenda, you confirm that you will:

Tell your health care professional if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath.
Drink plenty of fluids to avoid dehydration.

Confirm

Are you aware this treatment should be used as an adjunct to a healthy diet and increased physical activity? *

NoYes

Please confirm you're aware the treatment should be used in conjunction with a well-balanced diet.

If I have not lost at least 5% of my initial body weight after 12 weeks at the maximum daily dose of 3mg, I understand that I should discontinue treatment with Saxenda *

Confirm

We strongly advise that you inform your GP of any treatment you receive. Would you like us to inform them on your behalf? *

Please enter your postcode to display your local GP's

Please enter your GP surgery

Name
Address
Email
Telephone/Fax Number

Incorrect information may delay your order.

You can find your GP surgery information details below

Please enter your GP surgery name *

Please enter your GP surgery address. *

Please enter your GP surgery e-mail address. *

Please enter your GP surgery phone number *

Please enter your name *

Please enter the address registered with your GP. *

Please enter your date of birth. *

I understand that if I place an order for Saxenda after 3.30pm on a Thursday, Simple Online Pharmacy will not ship my order until the following Monday due to the medication being a temperature/time critical item. This applies even if you choose the 'next day delivery' option on the checkout page. This may change around public holidays so please look out for your delivery confirmation email. *

Confirm

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
If Saxenda does not help me realise my weight loss aims, I will consult my GP for further advice.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.
I agree to the Simple Online Pharmacy terms and conditions.

Confirm

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. *

Confirm

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. *

Confirm

I understand that if I take multivitamin supplements, these should be taken 2 hours after my Orlistat / Xenical dose, or at bedtime. *

Confirm

I confirm I am over 18 years old.

The medicine ordered is for my sole use only.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Pharmacy terms and conditions. *

Confirm

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

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