About the Condition and Treatment
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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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.
Kindly share your weight. Please provide an image of you standing on the scales.
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?
Do you have a history of having an eating disorder?
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?
Do you use any of the medications listed below?
Blood-thinning medications (such as warfarin).
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?
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.
Does any of the following statements apply to you:
Orlistat causes an allergic reaction or hypersensitivity in you.
What is your biological gender?
Please select your option
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
Can you relate to any of the following?
You have an underlying medical condition
Do you have any recent or past medical history of note?
If yes, please provide details
Have you received advice from a weight management counsellor before?
Have you tried to manage your weight by altering your diet and increasing physical activity?
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.
Would you object to a low-calorie diet as part of treatment?
Has a low-calorie diet failed to manage your weight in the past?
Do you currently have, or have a history of pancreatitis?
If yes, please provide details
Do you have any of the following listed below?
Dysglycaemia; Hypertension; Dyslipidaemia; Obstructive sleep apnoea.
Do you know your Body Max Index?
If yes, please list it below
Have you had a serious reaction to Saxenda before?
Are you currently using any weight management products?
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Do you have inflammatory bowel disease (ulcerative colitis, crohn's disease etc.)?
Do you have any endocrinological disorders or eating disorders?
If yes, please provide details
Do you have any liver, kidney or heart problems?
If yes, please provide details
Do you have any allergies?
If yes, please provide details
Women only: Are you breast feeding?
Please list all your current prescription medication including any medication you buy over the counter...
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