Weight Loss Consultation Form

Please fill in all aspects of this form to the best of your ability. Once completed, one of our medical team will contact you.

- Step 1 of 2

Please complete the personal and contact details stage of the form.

Title *MrMrsMissMsOther

Name *

First

Last

Age *18192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100

DOB *

Please enter your date of birth in the format DD/MM/YYYY

Phone Number *

Email *

Home Address *

Postcode *

Name and address of your GP *

Postcode for your GP *

Next

Please fill in the forms to calculate your BMI.

Please enter your weight in KG
Please enter your height in CM

Your BMI Calculation is:

1. Please enter the BMI number you have just been given *

2. Have you entered your BMI accurately? *

• Yes
• No

Unfortunately you are not suitable for prescription weight loss medication. If you would like further information about why you are not suitable please contact us on 01274 921121 and ask to speak to one of the medical professionals

Please re-enter your BMI number accurately into the field, before you can proceed.

Please provide details of your health in this stage.

3. I consent to undertaking a remote consultation *

• Yes
• No

Unfortunately you are not suitable for prescription weight loss medication. If you would like further information about why you are not suitable please contact us on 01274 921121 and ask to speak to one of the medical professionals

4. Have you recently had a blood pressure reading? *

• Yes
• No

4a. Please enter your blood pressure reading *

5. Are you aware of any allergies? *

• Yes
• No

5a. Please provide details of your allergies *

6. Are you aware of any hypersensitivity to Liraglutide? *

• Yes
• No

Unfortunately you are not suitable for prescription weight loss medication. If you would like further information about why you are not suitable please contact us on 01274 921121 and ask to speak to one of the medical professionals

7. Are you currently being treated with other weight management products? *

• Yes
• No

7a. Please provide us with more details *

8. Are you pregnant, planning pregnancy or is there a possibility you may be pregnant? *

• Yes
• No

Unfortunately you are not suitable for prescription weight loss medication. If you would like further information about why you are not suitable please contact us on 01274 921121 and ask to speak to one of the medical professionals

9. Are you currently breastfeeding? *

• Yes
• No

Unfortunately you are not suitable for prescription weight loss medication. If you would like further information about why you are not suitable please contact us on 01274 921121 and ask to speak to one of the medical professionals

10. Do you suffer from any of the following? (select all that do, or none of the above) *

• Diabetic gastroparesis
• Inflammatory bowel disease
• Ketoacidosis
• Congestive heart failure
• Obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain
• Severe renal impairment
• Severe hepatic impairment
• Pancreatitis
• Personal or family history of thyroid cancers or tumours
• None of the above

If none of these apply to you, please tick none of the above

Unfortunately you are not suitable for prescription weight loss medication. If you would like further information about why you are not suitable please contact us on 01274 921121 and ask to speak to one of the medical professionals

11. Do you or have you suffered from any kind of eating disorder? *

• Yes
• No

11a. Please provide us with more details *

12. Are you worried about how you look? *

• Yes
• No

12a. On a scale of 1 - 10 (10 being worried all the time, 0 being not at all) please quantify how worried you are. *012345678910

13. Are there things you avoid because of how you look? *

• Yes
• No

13a. Please provide us with more details *

14. Please list all your current prescription medication including any medication you buy over the counter. *

Enter N/A if this isn't applicable to you

15. Please provide details of any other recent or past medical history of note. *

Enter N/A if this isn't applicable to you

Do you confirm that your answers are true and accurate? *Select an optionYesNo

Unfortunately you are not suitable for prescription weight loss medication, please contact us on 01274 921121 and ask to speak to one of the medical professionals.

Please press the 'Enter/ Return' key to proceed, then press 'Proceed to book consultation'

Proceed to book consultation