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Account Information:
Step 1 - 6
First Name: *
Last Name: *
Address: *
City: *
PostCode: *
Phone: *
Email: *
Date of Birth: *
Age: *
Password: *
Confirm Password: *
Gender
Male
Female
Are you pregnant, breastfeeding or trying to get pregnant?*
Yes
No
This treatment is not suitable if you are pregnant, trying to get pregnant or breastfeeding. We recommend you speak to your GP in person.
Height
Meters
Inches
Weight
KG
LBS
What is your usual blood pressure range?*
Low - 90/60 or Below
Normal - Between 91/61 and 139/89
High - 140/90 or Above
I don't know
Attach full body picture
Next
Please be aware that it is important to give truthful information about your medical history.
About your Health:
Step 2 - 6
Do you suffer from any heart problems? *
Yes
No
For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.
Please, give details*
Do you have any thyroid problems?*
Yes
No
For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.
Please, give details*
Have you, or anyone in your immediate family ever had thyroid cancer? *
Yes
No
Please, give details*
Do you currently, or have you ever had pancreatitis? *
Yes
No
Please, give details*
Do you suffer from any kidney problems?*
Yes
No
Please, give details*
Do you suffer from any liver problems?*
Yes
No
For example: hepatitis, fatty liver, alcohol liver disease etc.
Please, give details*
Do you suffer from any SEVERE gastro-intestinal problems?*
Yes
No
For example: inflammatory bowel disease or gastroparesis etc
Please, give details*
Do you suffer with diabetes?*
Yes
No
Are you taking Insulin?*
Yes
No
Please, give details*
Do you suffer from any mental health problems?*
Yes
No
For example: severe anxiety, severe depression, schizophrenia, personality disorders, thoughts of suicide etc.
Please, give details*
Do you suffer with an eating disorder?*
Yes
No
For example: anorexia, bulimia, binge eating etc.
Please, give details*
Do you have any other medical problems?*
Yes
No
Please, give details*
Are you taking any other medication not already identified above?*
Yes
No
For example other prescribed medication, products purchased over-the-counter or herbal supplements
Please, give details*
Do you have any known allergies?*
Yes
No
Please, give details*
It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'YES' below to give us your permission to do so.*
Yes
No
GP Name: *
GP Practice Address: *
GP Phone Number*
GP Email*
Enter the details*
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About your lifestyle:
Step 3 - 6
Do you smoke?*
Yes
No
Smoking increases the risk of serious health issues. You can
find more information about quitting here.
How many per day?
Select from the list
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
40+
Do you drink alcohol?*
Yes
No
How many units per week? Copy and paste this link to calculate your units
https://www.drinkaware.co.uk/sevendaycalculator
Select from the list
1-5
6-10
11-15
16-20
21-25
26-30
31 +
Excessive alcohol consumption can increase the risk of serious health issues. To get help with cutting down drinking,
visit this page.
How many cups of tea or coffee do you drink each day?*
Select from the list
none
1-2
3-4
5-6
7-8
9 +
How many glasses of water do you drink each day?*
Select from the list
none
1-2
3-4
5-6
7-8
9 +
NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation
How many hours of sleep do you average each night?*
Select from the list
less than 4
5-6
7-8
8 +
Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.
How much exercise / activity do you do each week?*
Select from the list
Very little
One hour
Two to Three hours
More than Three hours
NB. This doesn't have to be set time in the gym, it can be ANY activity that gets your heart pumping. (Current guidelines recommend 150 minutes of moderate aerobic activity or 75 minutes vigorous activity per week)
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Your weight-loss journey:
Step 4 - 6
How many calories do you consume per day?*
Select from the list
less than 1000
1000-1500
1501-2000
2001-2500
More than 2500
Please describe your typically daily diet *
What contributes to your excess weight? (Please tick ALL that apply)*
Large portion sizes
Emotional eating
Compulsive eating
Reward eating
Waking and eating at night
Eating out / Takeaways
Medication
Yo-Yo dieting
Snacking between meals
Lack of exercise
Lack of will power
Lack of motivation
Limited mobility
Other
Please tell us what weight loss interventions you have previously tried*
For example: weight watchers, slimming world, increased exercise, went to see GP, medication etc
Are you currently taking any weight loss treatments such as Xenical, Alli, Mysimba, Saxenda, Ozempic or Phentermine, Wegovy, Mounjaro?*
Yes
No
Which one, and how long have you been taking it?*
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Declaration & Consent:
Step 5 - 6
Kindly TICK to confirm that you agree with each of the following statements if you wish proceed with treatment, then please sign your name below
I confirm that I have answered all the above questions truthfully*
Yes
Should I experience any changes in my medical history, I will immediately inform the clinic*
Yes
I understand that any weight loss treatment MUST be used in conjunction with a reduced calorie diet, and increased physical activity for best results.*
Yes
I agree to record my daily food intake and physical activity*
Yes
I agree to follow the guidelines provided*
Yes
I confirm that no guarantees for weight loss have been given, and that results will vary from individual to individual. I am also aware that around 1 - 2% of people do not respond to treatment, but the reason for this is unknown, and I accept this possibility*
Yes
I agree to read the patient leaflet before starting the Pen*
Yes
I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment*
Yes
Patient Signature*
Append your signature in the box below
How did you find us?*
Website link
Facebook link
Instagram link
Link in an email we sent
Link in a message we sent
Through a friend
Other
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Readiness to change:
Step 6 - 6
This questionnaire is designed to help you and your practitioner decide if this is a good time in your life for you to begin a weight management Programme. Just be as honest with yourself and select the answers you feel most apply to you.:
Do you feel motivated to lose weight at this time?*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
How motivated are you to change your eating habits at this time?*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
How motivated are you to increase your physical activity at this time?*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
How motivated are you to try new strategies/techniques for changing your dietary, physical activity and other health related behaviors at this time?*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
People who want to achieve long-term weight control need to spend time every day trying to plan for healthy meals, physical activity and behavior change. How confident are you that you can devote time and effort, now and over the next few months?*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
How confident are you that you will be able to record everything you eat and drink and your activity each day for 2-4 weeks?*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
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