Weight Loss - Consultation

What is your date of birth?

What is your current height?

Allowed values range from 100cm to 220cm

Switch to ft, in

What is your current weight?

Allowed values range from 40kg to 250kg

Switch to st, lb

How long have you been trying to lose weight?

Which methods have you tried?

What is your main reason for wanting to lose weight?

Are you willing to continue lifestyle and dietary changes alongside treatment?

Yes

Have you been diagnosed with any medical conditions?

Please list ALL medications you are currently taking.

Do you have any medication allergies or previous drug reactions?

Yes

Have you ever had pancreatitis (inflammation of the pancreas)?

Yes

Have you had gallstones or gallbladder disease?

Yes

Do you have severe digestive problems, such as delayed stomach emptying or ongoing severe reflux?

Yes

Do you have a personal or family history of medullary thyroid cancer or Multiple Endocrine Neoplasia type 2 (MEN2)?

Yes

Have you ever been diagnosed with an eating disorder (including anorexia, bulimia, or binge eating disorder)?

Yes

Do you have any mental health conditions that may affect your treatment?

Yes

Do you have type 1 diabetes?

Yes

Are you currently taking insulin?

Yes

Are you currently using another weight loss medication or injection?

Yes

Have you previously had bariatric (weight loss) surgery?

Yes

Are you currently pregnant?

Yes

Are you breastfeeding?

Yes

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Are you planning to become pregnant within the next 3 months?

Yes

Are you currently experiencing ongoing severe nausea, vomiting, or unexplained abdominal pain?

Yes

Is there anything else you would like our prescriber to know? (Optional)

Please confirm:

I understand weight management medication supports, but does not replace, healthy lifestyle changes.
I understand results vary between individuals.
I understand side effects can occur and I will read the Patient Information Leaflet.
I will seek medical advice if I experience severe side effects.
I confirm the information provided is accurate and complete to the best of my knowledge.

I confirm that I understand and agree to the above

Would you like us to inform your GP about your treatment?

Yes

To support safe prescribing please provide your GP details.

Yes

Do you consent to us contacting your GP if clinically necessary for your safety?

Yes