Myonlinedoctor Erectile dysfunction treatment Registration Page

In order to prescribe treatments for Weight loss our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

To date, have you ever taken any weight loss prescription treatments such as Reductil, Xenical, Acomplia, Saxenda/Victoza or Phentermine? If yes which one and when did you last take this treatment?

Yes No

Are you currently on a course of any of the weight loss prescription treatments mentioned above?

Yes No

If you wish to obtain a repeat prescription for a treatment you are currently taking please tell us how much weight you have lost since you have started using the medication and provide the exact name and dosage of this treatment.

Yes No

Is there any psychological cause for your condition (e.g. Anxiety or Depression)?

Yes No

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

Yes No

Do you suffer from diabetes or have high cholesterol levels and if so, how are these conditions controlled?

Yes No

Do you suffer from severe hepatic (liver) impairment?

Yes No

Do you suffer from severe renal (kidney) impairment?

Yes No

Do you suffer from Epilepsy?

Yes No

Do you suffer from any of the following rare hereditary problems: Galactose intolerance, the Lapp Lactase deficiency or a glucose-galactose malabsorption?

Yes No

Do you suffer from bowel problems like Crohns disease or ulcerative Colitis?

Yes No

How else have you tried to treat your condition?
Have you consulted your GP? (When was the most recent visit to your GP)
Have you tried regular exercise and a controlled diet?
Is there anything else which you have tried to help remedy the condition?

Please provide full details

I understand that I must have exhausted all other methods of trying to control my weight problem before any prescription treatments can be used.

Are you pregnant, breastfeeding or planning to start a family soon?

Yes No

Do you regularly eat chocolate or crisps?

Yes No

Do you regularly eat takeaways eg pizza?

Yes No

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