UKweightloss

About You
About Your Health
About Your Lifestyle
Weightloss Journey
Declaration & Consent
Readiness to change

Account Information:

Step 1 - 6

First Name: *

Last Name: *

Gender

Male

Female

Are you pregnant, breastfeeding or trying to get pregnant?*

Yes

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

LBS

Attach Picture

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

For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.

Please, give details*

Do you have any thyroid problems?*

Yes

For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.

Please, give details*

Have you, or anyone in your immediate family ever had thyroid cancer? *

Yes

Please, give details*

Do you currently, or have you ever had pancreatitis? *

Yes

Please, give details*

Do you suffer from any kidney problems?*

Yes

Please, give details*

Do you suffer from any liver problems?*

Yes

For example: hepatitis, fatty liver, alcohol liver disease etc.

Please, give details*

Do you suffer from any SEVERE gastro-intestinal problems?*

Yes

For example: inflammatory bowel disease or gastroparesis etc

Please, give details*

Do you suffer with diabetes?*

Yes

Are you taking Insulin?*

Yes

Please, give details*

Do you suffer from any mental health problems?*

Yes

For example: severe anxiety, severe depression, schizophrenia, personality disorders, thoughts of suicide etc.

Please, give details*

Do you suffer with an eating disorder?*

Yes

For example: anorexia, bulimia, binge eating etc.

Please, give details*

Do you have any other medical problems?*

Yes

Please, give details*

Are you taking any other medication not already identified above?*

Yes

For example other prescribed medication, products purchased over-the-counter or herbal supplements

Please, give details*

Do you have any known allergies?*

Yes

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

GP Name: *

GP Practice Address: *

About your lifestyle:

Step 3 - 6

Do you smoke?*

Yes

Smoking increases the risk of serious health issues. You can find more information about quitting here.

How many per day?

Do you drink alcohol?*

Yes

How many units per week? Copy and paste this link to calculate your units https://www.drinkaware.co.uk/sevendaycalculator

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?*

How many glasses of water do you drink each day?* 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?*

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?*

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)

Your weight-loss journey:

Step 4 - 6

How many calories do you consume per day?*

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

Which one, and how long have you been taking it?*

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*

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

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

Make an Appointment

Account Information:

Step 1 - 6

Height

Weight

About your Health:

Step 2 - 6

About your lifestyle:

Step 3 - 6

Your weight-loss journey:

Step 4 - 6

Declaration & Consent:

Step 5 - 6

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.: