Female Patients Form 4

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Female - Weight Loss Treatment

Put your details

Pharmacy Name*

Pharmacy Location*

Pharmacy EirCode*

What sex were you born as?

FEMALE MALE

What is your current height (enter as centimeters)?

What is your current height (enter as kg)?

What forms of weight loss have you tried in the past?

DIETING (INCLUDING WEIGHT WATCHERS ETC) EXERCISE SUPPLEMENTS MEDICATION NONE If other, please specify:

Have you been diagnosed with high blood sugar levels or diabetes?

NO If YES, I DO, please specify:

Do you currently suffer from either heart disease, high blood pressure or are you being prescribed a treatment for high blood pressure?

NO If YES, I HAVE, please specify:

Have you been diagnosed with any liver issues?

NO If YES, I HAVE, please specify:

Have you ever been diagnosed with any kidney issues?

NO YES, THERE WAS, please specify:

Were you diagnosed with a food assimilation issue such as chronic malabsorption syndrome?

NO YES

Have you ever had any form of gastric surgery, such as removal of any part of your GI tract?

NO If YES, I HAVE, please specify:

Have you ever suffered from obstructive sleep apnoea?

NO YES

Are you currently pregnant or planning to be pregnant (within the next 6 months)?

NO YES

Are you currently breastfeeding?

NO YES

Are your daily activities currently affected by your weight?

YES NO

Even after being rested, do you still feel tired and lacking energy?

Have you noticed a dramatic loss of interest in sex, exercise or work?

Have you been diagnosed with a form of eating disorder - anorexia or bulimia, either currently or in the past?

NO If YES, I HAVE, please specify:

Have you noticed it difficult when it comes to thinking, remembering or making decisions?

Do you feel sad or anxious for 2 weeks or more on a continuous basis?

YES NO If OTHER, please specify:

Do you exercise regularly?

NO If YES, I DO, please specify:

Are you currently a smoker?

Do you drink alcohol - weekly consumption (1 unit = 125ml wine, ½ pint beer)?

In the last 2 months, have you taken any prescription, non-prescription, recreational/illegal drugs other than the medications you have outlined earlier in this form?

NO If YES, I HAVE, please specify:

Do you currently take any medication for the treatment of HIV, Depression, Epilepsy or Cyclosporin or Warfarin?

NO If YES, I AM, please specify frequency and dosages:

Have you ever taken Xenical in an attempt to assist your weight loss?

NO If YES, I HAVE, please specify frequency and dosages:

Do you have any known allergies?

NO If YES, I HAVE, please specify:

What age are you?

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown)

I confirm that I have understood fully and read in full all of these questions and that my answers are true and accurate, to the best of my knowledge..

I CONFIRM I DO NOT CONFIRM

Complete the prescription form below. If the doctor determines that an prescription is not appropriate for your case, you will be refunded.

EXPRESS SickCert: Prescription within 24hrs sent via email. 29.99 EUR

*This will be reviewed and signed by an Irish doctor and is emailed to you within 24 hours.

RECOMMENDED: Prescription will be prioritised in the queue and sent via email. 24.99 EUR

*This will be reviewed and signed by an Irish doctor, sent via email and your request will be at the top of the request queue.

EMAIL: Prescription will be sent via email within 2-3 working days 19.99 EUR

*This will be reviewed and signed by an Irish doctor and sent via email, usually delivered within 2-3 working days.

I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side of my face or limbs or body, slurred speech. I confirm I do not think I need to see a GP. I confirm that this is not a replacement for a doctor's visit. I have read, understood and agree with the information in the terms of service and consent to the use of information in accordance with the (privacy policy).

I CONFIRM I DO NOT CONFIRM

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Female Patients Form 4

Female - Weight Loss Treatment

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