Do you suffer from diabetes, heart disease, high blood pressure or high cholesterol?*

Our doctors need to know this because medications for diabetes and heart related conditions can impact the way the medication included with our weight loss plan works.

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

Do you suffer from depression?*

Have you ever had any suicidal thoughts?*

Are you allergic to any of the following *

• Wegovy medications
• Orlistat
• Salcaprozate sodium
• Povidone K90
• Cellulose, microcrystalline
• Magnesium stearate
• Anything else

Have you been diagnosed with any of the following *

• Liver, kidney or heart failure
• Pancreatitis
• Multiple endocrine neoplasia type 2 (MEN 2)
• Cancer
• Type 1 diabetes or diabetic retinopathy
• Type 2 diabetes
• Personal or family history of medullary thyroid cancer
• History or ongoing gallbladder problems
• History or ongoing Inflammatory bowel disease or gastroparesis
• Problems absorbing food (chronic malabsorption syndrome) diagnosed by a doctor
• Thyroid problems
• Fatty liver disease
• any serious medical condition which may require immediate hospitalisation

Have you ever taken any medications for weight loss treatment?*

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

Do you confirm you understand the following:*

• If you’re eligible for the prescribed treatment, you cannot take more than one weight loss medication at a time.
• Weight loss medication should be used alongside lifestyle changes such as exercise and a reduced-calorie balanced diet.
• You have tried to lose weight through diet, exercise and lifestyle changes prior to using any prescription medicines.
• Rybelsus are not licensed for weight loss. You must read the information on off-label use of medicines before proceeding, understand the benefits and risks associated with using these medicines and consent to using it as an off-label medicine.

Do you agree with the following?*

• 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.
• If you experience any sudden change to your mood, behaviour or thoughts while taking this medication (e.g. depression or suicidal thoughts), you will stop treatment and seek immediate medical advice.
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start a new medication or if your medical conditions change during treatment.
• You give permission to contact your GP to inform them of your treatment.
• If you are a woman of childbearing age, you will take any necessary precautions to ensure that you do not get pregnant while you are using this medication or for two months after stopping the treatment as this medication can harm an unborn child.
• You will read the patient information leaflet included with the medication before starting treatment. If you have any concerns, you will not start treatment before contacting your doctor.