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Weight Loss Health Questionaire (for new patients)
Name *
Telephone number *
Email address *
Date of Birth *
Registered GP surgery
Current weight and height *
1. Have you had any other weight loss medications before? *
Yes
No
2. Have you ever had weight loss (bariatric) surgery? *
Yes
No
3. Do you take any medications, such as amiodarone, ciclosporin, diabetes medications, epilepsy medications, HIV treatment, medications that affects the immune system, methotrexate, warfarin, and other over-the-counter medications? *
Yes, please type in below on next question
No
3a. Do you take any long term medications, either prescribed, over-the-counter, or herbal?
4. Do you have any of the following medical conditions, or any long-term medical conditions? *
• Diabetes, includes pre-diabetes, diabetes in remission, diabetes in pregnancy
• Bowel and gut conditions (Crohn’s disease, ulcerative colitis, diverticular disease, IBS)
• Thyroid disease
• Cancer (now or in the past)
• Heart disease (cardiomyopathy, heart failure, irregular heart beat)
• High blood pressure
• Gallbladder, gallstones, bile problems
• Kidney disease, liver disease
• Pancreatitis
• None of the above
4a. Please state if you have any chronic medical conditions or any other medical conditions, illnesses, hospital stays or past surgical procedures?
5. Do you have a history of thyroid disorders or family history of thyroid cancer? *
Yes
No
7. Do you have any known allergies? Please state: *
8. Are you pregnant or breastfeeding? *
Yes
No
NA
9. Wegovy/Mounjaro shouldn’t be taken if you’re trying to get pregnant. Use contraception whilst taking it. Are you trying to get pregnant? *
• Yes, I'm trying to get pregnant
• Yes, I'm waiting for IVF
• No or not applicable to me
Any other comments please mention here:
Leave this field empty
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Please book a video consultation with a clinician if you are new to treatment.
For returning customers, please proceed to product page for check out.