Step 2: Medical History – Orlistat Consultation

Are you currently taking any of the following medication? *

YesNo

Please explain

Are you currently taking any other prescription-only medicines, alternative medicines or recreational drugs? This includes the contraceptive pill. *

YesNo

Please explain

Do you have any known allergies? *

YesNo

Please explain

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

YesNo

Please explain

Have you ever been diagnosed with chronic malabsorption syndrome (difficulty absorbing nutrients from your food) by your GP? *

YesNo

Please explain

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

YesNo

Please explain

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

YesNo

Please explain

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

YesNo

Please explain