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Weight Management Online Assessment Form

Step 1 of 6 - About you

Name
Address
Contact Information
Date of birth
Height
Weight
BMI
What is your usual blood pressure range?

Please be aware that it is important to give truthful information about your medical history.

Do you suffer from any heart problems?

For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.

Do you suffer from any thyroid problems?

For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.

Have you, or anyone in your family ever had thyroid cancer?
Do you currently, or have you ever had pancreatitis?
Do you suffer from any kidney problems?
Do you suffer from any liver problems?
Do you suffer from any SEVERE gastro-intestinal problems?

For example: inflammatory bowel disease or gastroparesis etc?

Do you suffer from diabetes?
Do you suffer from any mental health problems?

For example: anxiety, depression, schizophrenia, personality disorders, thoughts of suicide etc.

Do you suffer with an eating disorder?

For example: anorexia, bulimia, binge eating etc.?

Do you have any other medical problems?
Please give details
Are you taking any other medication not already identified above?
Please list all medicines and what they treat.
Do you have any known allergies?

It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'YES' below to give us your permission to do so.

Do you smoke?
How many per day?

Smoking increases the risk of serious health issues. You can find more information about quitting here.

Do you drink alcohol?
How many units per week?

Calculate your units here

Excessive alcohol consumption can increase the risk of serious health issues. To get help with cutting down drinking, visit this page.

How many cups of tea or coffee do you drink each day?
How many glasses of water do you drink each day?

NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation

How many hours of sleep do you average each night?

Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.

How much exercise / activity do you do each week?

NB. This doesn't have to be set time in the gym, it can be ANY activity that gets your heart pumping. (Current guidelines recommend 150 minutes of moderate aerobic activity or 75 minutes vigorous activity per week)

How many calories do you consume per day?
Do you eat three meals a day?
Please describe your typical daily diet
What contributes to your excess weight?
Have you previously or are you currently taking any weight loss treatments such as Xenical, Alli, Mysimba, Saxenda, Ozempic or Phentermine?
Please describe which one and when did you last take this treatment? How long did you take the treatment for?
Please tell us what weight loss interventions you have previously tried

I confirm that I have answered all the above questions truthfully

Should I experience any changes in my medical history, I will immediately inform the clinic

I understand that the Pen MUST be used in conjunction with a reduced calorie diet, and increased physical activity for best result

I agree to record my daily food intake and physical activity

I agree to follow the guidelines provided

I confirm that no guarantees for weight loss have been given, and that results will vary from individual to individual. I am also aware that around 1 - 2% of people do not respond to treatment, but the reason for this is unknown, and I accept this possibility

I agree to read the patient leaflet before starting the Pen

I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment

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