Weight Loss Management

Please complete your confidential clinical assessment. Evaluated by GMC & GPhC registered healthcare professionals.

About You

▾

Please enter your GP name and address *

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you? *

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

⚠️

We need your consent to inform your GP about your weight loss medications.

Do you believe you have the capacity to make decisions about your own healthcare? *

⚠️

You must have the capacity to make decisions about your own healthcare to proceed. Please see your GP.

Symptoms

▾

What is your target weight? *

Have you previously tried to lose weight by diet and exercise alone? *

Have you ever suffered from an eating disorder? *

Please provide more detail about this.

Health

▾

Are you currently using any weight loss medication? Including Mounjaro, Wegovy, Saxenda, Orlistat, Xenical purchased from ourselves or elsewhere. *

Please provide more detail about this.

Do you take any of the following medicines? *

Medicines that thin the blood (such as warfarin).
Acarbose (to treat diabetes).
Ciclosporin (to prevent organ rejection).
Lithium (for mental health problems).
Amiodarone (for heart problems).
Medicines to treat epilepsy or seizures.
Levothyroxine (to treat low thyroid levels).
Medicines to treat HIV.
Medicines to treat psychosis or other mental health issues

Please provide more detail about this.

People with weight-related medical conditions may be prescribed weight loss medicines at a lower BMI than other patients, if suitable. Please let us know if you have any of the following weight-related conditions: *

Acid Reflux GORD Cardiovascular disease Erectile Dysfunction Pre-Diabetes Hypertension Obstructive Sleep Apnoea Dyslipidaemia (high cholesterol levels) Polycystic Ovary Syndrome (PCOS) Peri-menopause/ Menopause None of the above

How many calories do you consume daily? *

How often do you eat unhealthy food? This could include: chocolates, processed foods, frozen foods, foods containing high sugar content. *

Please upload a full picture of yourself showing your full length. If possible please kindly upload an image of scales showing what your current weight is when standing on them. *

These images will only be used and be visible to the medical professional providing the treatment
We understand that this may be inconvenient too many, however we request these photos to ensure the safety of our patients due to the medication they have requested.

Do you smoke? *

Do you drink alcohol? *

Are you pregnant or breastfeeding? *

Do any of the following apply: *

You suffer with any medical conditions that you have not already mentioned
You have had major surgery
You have allergies
You have heart problems or have had a stroke
You have decreased kidney or liver function

Please provide more detail about your condition

What is your blood pressure? *

Do you suffer with thyroid problems? *

Do you take medication for this? Do you have an under or over active thyroid?

Are you aware if you take the contraceptive pill, it is recommended that you use an additional contraceptive method, especially if you suffer from diarrhoea *

Medication

▾

Are you currently taking any medication (including over the counter, prescription or recreational drugs)? *