Questionairre for Weight Loss

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
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

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