Patient Information

Are you (or is your child) older than 12 years old?

For females, are you pregnant or  breastfeeding?

Patient Symptoms

Are you overweight with hypertension, diabetes mellitus, or dyslipidemia (high levels of fats/cholesterol) or obese?

Do you experience any of the following?

• Yellowing of the skin/eyes
• Oily stools
• Light-colored stools
• Episodes of binge eating
• Self-induced vomiting

Medical History

Do you have any of the following?

• Thyroid disease
• Liver disease
• Kidney disease 
• Type 1 or 2 diabetes

Do you have allergies to orlistat?

Are you currently taking any of these drugs?

• Blood thinners (warfarin)
• HIV medications
• Thyroid hormones (levothyroxine)
• Anti-epileptic drugs (valproate, lamotrigine)

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will still eat a balanced diet and exercise while on this medication
• You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• You may have to use additional methods of contraception if you are using oral contraceptive pills as this drug may reduce its efficacy
• 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
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber