Weight Assessment Weight Management Assessment Contact DetailsName(Required) First Name Last Name Phone(Required)Email(Required) Date of Birth(Required) DD slash MM slash YYYY AgeAddress(Required) Street Address City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Name of the PharmacyME360 ClinicPickfords PharmacyOtherEnter the name of the PharmacyWeight AssessmentYour Height(Required)Please enter a number from 1 to 8.Inches(Required)Please enter a number from 0 to 11.Weight Unit KGs ST + LB Your Weight (KGs)(Required)Stones(Required)Please enter a number from 0 to 40.Pounds(Required)Please enter a number from 0 to 13.This field is hidden when viewing the formSTLB to KGsBMIDo you suffer from prediabetes, diabetes, heart disease, high blood pressure, high cholesterol, or obstructive sleep apnoea?(Required) Yes No If Yes, please specify(Required) Prediabetes Diabetes High Blood Pressure High Cholesterol Obstructive Sleep Apnoea About YouIf you have type 2 diabetes, are you on any insulin injections?(Required) Yes No Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda, or Liraglutide before?(Required) Yes No Have you ever suffered with an eating disorder?(Required) Yes No Are you pregnant, breastfeeding, or trying to conceive?(Required) Yes No Have you been diagnosed with or had surgery for any of the following?(Required) Acromegaly or any growth hormone problem Chronic Malabsorption Syndrome Cushings Syndrome Gallbladder, Bile duct or Pancreas disease Gastric surgery (bariatric surgery) Heart Failure Hypoglycaemia Kidney Disease Liver Disease Pancreatitis Severe gastrointestinal disease (e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease) Type 1 Diabetes None of the above Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer, or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?(Required) Yes No MedicationAre you currently taking any medication (including over the counter, prescription, or recreational drugs)?(Required) Yes No If Yes, please specify(Required)Are you taking steroids or medication to treat your thyroid?(Required) Yes No Have you taken injectable weight loss medication in the last 4 weeks?(Required) Yes No AgreementDo you agree to the following?(Required)1. You will read the patient information leaflet supplied with your medication 2. You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. 3. The treatment is solely for your own use 4. 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. Yes No Do you understand that GLP-1 injectable weight-loss medication (such as Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment?(Required) Yes No Do you understand that this medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?(Required) Yes No Do you understand that there may be an increased risk of pancreatitis, gall bladder problems, and gallstones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?(Required) Yes No Do you understand that injectable weight loss medications should not be used with other weight loss medications?(Required) Yes No Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?(Required) Yes No Both weight loss and injectable weight loss treatment have been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self-harm, or other mental health issues), do you understand you should stop treatment and speak to your doctor?(Required) Yes No PhoneThis field is for validation purposes and should be left unchanged.
