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Weight Assessment

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Weight Assessment

Weight Assessment

14/02/2025 2025-02-14 9:17

Weight Assessment

Weight Management Assessment

Contact Details

Name(Required)

First Name Last Name

Phone(Required)

Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age

Address(Required)

Street Address City ZIP / Postal Code Country

Weight Assessment

Your Height(Required)

Please enter a number from 1 to 8.

Inches(Required)

Please enter a number from 0 to 11.

Your Weight (in KGs)(Required)

BMI

Do 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 You

If 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

Medication

Are 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

Agreement

Do 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

Phone

This field is for validation purposes and should be left unchanged.