This worksheet can help facilitate a productive discussion with your doctor about your
weight-loss goals and options. The information you provide on this worksheet will help your
doctor determine the weight-loss approach that is right for you.
To use the worksheet, just print it out, fill it in and take it with you to your doctor
How tall are you? ___ feet ___inches
How much do you weigh? ____
What is your Body Mass Index (BMI)? ___
(To determine your BMI, use the BMI Calculator at www.xenical.com)
How much weight would you like to lose? (check one)
More than 40 lbs
Why would you like to lose weight? (check all that apply)
I’d like to improve my health.
I’d like to look better.
How do you feel about yourself and your current weight? (please describe below)
What weight-loss methods have you tried before? (check all that apply)
Diet programs and support groups
Over-the-counter diet pills
Prescription weight-loss medications
How would you describe your experiences with the weight-loss methods you’ve listed above?
Do you or any of your family members have, or have you or they had, any of the following
medical conditions or illnesses? (check all that apply)
Congestive heart failure
How often do you engage in physical activities?
Three or more times a week
Once a week
Once or twice a month
I am not able to engage in physical
activity for the following reason(s): (describe below)
Which of the following weight-loss options are you interested in pursuing? (check all that apply)
A healthy eating plan
Appropriate physical activity
Prescription medication options
XENICAL is a prescription medicine used with a low calorie diet to increase weight loss in people with obesity. XENICAL may help obese people lose weight and keep the weight off.
It is not known if XENICAL is safe and effective in children under 12 years old.
Important Safety Information
Do not take XENICAL if you:
are pregnant. A minimum weight gain, and no weight loss, is currently recommended for all pregnant women, including those who are already overweight or obese.
have food absorption problems (chronic malabsorption syndrome)
have gallbladder problems (cholestasis)
are allergic to orlistat or any of the ingredients in XENICAL
Before you take XENICAL, tell your doctor if you:
have liver problems
have kidney problems
have problems with your thyroid
have eating problems such as anorexia or bulimia
are breastfeeding or plan to breastfeed. It is not known if XENICAL passes into your breast milk. Talk to your doctor before you breastfeed and take XENICAL.
Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements.
XENICAL may cause serious side effects, including:
Lowered absorption of certain vitamins in your body. Take a multivitamin containing vitamins A, D, E, K, and beta-carotene one time each day. Take a multivitamin at least 2 hours before or after you take XENICAL, such as at bedtime.
Severe liver problems. Stop taking XENICAL and call your doctor right away if you have the following symptoms of liver problems:
loss of appetite
yellowing of your skin or the white part of your eyes
light-colored bowel movements (stools)
pain in the upper right portion of your stomach
Kidney problems. Your doctor may do certain tests to check your kidney function during treatment with XENICAL. Call your doctor right away if you have the following symptoms of kidney problems:
swelling, especially of the legs and feet
little or no urine output
frequent or painful urination
blood in the urine
loss of appetite, nausea and vomiting
severe pain in the back, belly or groin
Gallbladder problems (gallstones). Call your doctor right away if you have the following symptoms of gallstones:
pain in the upper right portion of your stomach
The most common side effects of XENICAL include:
oily* rectal discharge
passing gas with oily discharge*
urgent need to have a bowel movement
oily* or fatty stools
increased number of bowel movements
being unable to control your bowel movements
*Oily discharge may be clear or have an orange or brown color.
How should I take XENICAL?
Take XENICAL exactly as your doctor tells you to take it.
Your doctor will tell you how much XENICAL to take and when to take it.
Take XENICAL with your meals or up to one hour after your meal. If you miss a meal or have a meal without fat, you can skip your dose of XENICAL. If you take a cyclosporine medicine, take XENICAL and cyclosporine at least 3 hours apart. See "What should I tell my doctor before taking XENICAL?" for a complete list of cyclosporine medicines.
If you take a multivitamin, take it at least 2 hours before or after you take XENICAL. Bedtime is a good time to take your multivitamin.
Take XENICAL with a nutritionally balanced, low calorie diet that has no more than about 30% of calories from fat. Taking XENICAL with any meal high in fat (more than 30% fat) may make the common side effects worse.
If you take too much XENICAL call your doctor or go to the nearest hospital
emergency room right away.
These are not all the possible side effects of XENICAL. For more information, ask your doctor or pharmacist.
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.