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Assessment Progress

1About You
2Your health
3Consent

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

Recommended Reading >>> NHS Weight Loss Guide

Are you aged between 18-65? *

NoYes

Please provide your age *

Please enter your height and weight *

Height (cm) *

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

Weight ( kg ) *

Height (Feet) *

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

Weight (Stone / Pounds) *

BMI

Please note, we may contact you to ask you to provide evidence of your current weight

People with weight-related medical conditions may be prescribed this medicine at a lower BMI than other patients, if suitable. Do you have any of the following weight-related conditions?

Non-alcoholic fatty liver disease
Non-alcoholic steatohepatitis (NASH)
On treatment for Depression linked to your weight
Cardiovascular disease (such as heart attack, Atrial Fibrilation)
Knee or hip osteoarthritis
Asthma
COPD
Obstructive sleep apnoea
Pre-diabetes
Polycystic ovary syndrome (PCOS)

*

NoYes

Please provide more information below: *

Are you currently using any weight loss medication? *

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 *

Please tell us which other weight loss medication you are using: *

Are you aware that you should only be using one weight loss medication at a time? You must not use two weight loss medications at the same time. *

NoYes

Please confirm that you understand you cannot take two or more weight loss medications at the same time

2Your health

Are you currently taking any of the following medication?

Ciclosporin
Warfarin
Antiepileptic Medication
Antiretrovirals
Acarbose
Amiodarone

*

NoYes

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

NoYes

Please give more details; list any medication you are taking. *

Do you have any known allergies? *

NoYes

Please give more details *

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.

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

NoYes

Please provide more information below. *

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

NoYes

Please provide more information below. *

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

NoYes

Please provide more information below. *

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

NoYes

Please provide more information below. *

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

NoYes

Please provide more information below. *

Have you ever made yourself sick (vomit) to control your shape or to lose weight? *

NoYes

In the last year, have you taken laxative medication in order to lose weight? *

NoYes

Do you worry that you have lost control over how much you eat? (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time?) *

NoYes

Would you say that food or image dominates your life? *

Do you ever eat in secret? *

NoYes

We are now asking for at least TWO selfies/ full body photos to support clinical assessment on suitability for treatment. These images will only be seen and reviewed by our clinical team

Position the camera so it captures your upper body. A full body selfie is preferred.
One image should be at a front facing angle and the other a side profile.
All photos should be taken recently- to demonstrate this, PLEASE WRITE THE DATE ON A PIECE OF PAPER AND HOLD IT UP in at least one of your photos
Wear just one layer of form-fitting clothing to allow accurate assessment.
Image should be well lit and in focus without glare/obstructions

*

Upload 2nd photo here: *

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide any additional information below: *

3Consent

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

In the interest of patient safety, our prescribers now need your GP details so we can notify them of this supply. Please confirm that you understand. *

NoYes

Please enter your postcode to display your local GP's

You must provide your GP details before you can proceed.

Please enter your GP’s name and surgery address. Please also enter their email address and fax number, if you know it.

You can find your GP surgery information details below

Please enter your GP surgery name *

Please enter your GP surgery address and post code *

Please enter your GP surgery email

I confirm I am over 18 years old.

I confirm this treatment is for me, and I consent to this treatment.

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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