Are you using an oral contraceptive?

Are you taking any medicine for high cholesterol, diabetes or high blood pressure?

Are you currently taking any medication from following (including over the counter, prescription or recreational drugs)?

Other Anti-Obesity Drugs HIV Medication Fat Soluble Vitamins Oral anticoagulant drugs used to thin the blood such as Warfarin Ciclosporin, used after organ transplants, for severe rheumatoid arthritis and some severe skin conditions a thyroid medicine (levothyroxine) Iodine salts Amiodarone, used for heart rhythm problems. Acarbose (an anti-diabetic drug used to treat type 2 diabetes mellitus) Anti-convulsant/anti-epileptic drugs Antidepressants Antipsychotics including lithium Benzodiazepines including diazepam

Do you agree to the following?

You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. 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.

Do you understand that treatment cannot be continued if you gain weight 3 months after starting the treatment?

Do you understand that the treatment must be stopped once your BMI goes below 28?

Do you understand the treatment should be taken with a nutritionally balanced, calorie controlled diet that contains approximately 30% of the calories from fat? It is recommended that your diet is rich in fruit and vegetables.

Do you understand that you should take a multivitamin that contains vitamins D, E, and K and beta carotene? It should be taken once a day at least 2 hours before or after taking Orlistat (Xenical/Alli/Orlos) such as at bedtime.

Have you ever suffered from an eating disorder such as Anorexia Nervosa or Bulimia?

Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking medication?

Are you allergic to orlistat?

Have you been diagnosed with any of the following?

Problems absorbing food (chronic malabsorption syndrome) diagnosed by a doctor Liver problems Kidney problems Thyroid problems Surgery to remove your gall bladder (cholecystectomy) Cholestasis (condition where the flow of bile from the liver is blocked) any serious medical condition which may require immediate hospitalisation