Questionnaire for returning customers

Name *

Email address *

Date of Birth

Address

Mobile *

Up-to-date Weight *

Have you experienced any side-effects since starting the medication? *

No
Nausea and vomitting
Stomach upsets
Diarrhoea
Constipation
Others, please state below

Other side effects please mention here:

Please let us know if you have made any lifestyle improvements since starting the medications? Ie diet changes, more exercises etc. *

It is considered safe to up-titrate the dose after 4 weeks, would you like to increase the dose? *