Consultation Form

Please fill in all fields before proceeding.

About You

Name*
Address*
Phone number*
Email Address*
Date of birth*
Age*
Gender*
Are you pregnant, breastfeeding or trying to get pregnant?*
Weight*
Height*
What is your usual blood pressure range?*

About your health

Please be aware that it is important to give truthful information about your medical history.

Do you suffer from any heart problems?*

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

Please give details*
Do you have any thyroid problems?*

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

Please give details*
Have you, or anyone in your immediate family ever had thyroid cancer?*
Please give details*
Do you currently, or have you ever had pancreatitis?*
Please give details*
Do you suffer from any kidney problems?*
Please give details*
Do you suffer from any liver problems?*

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

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

For example: inflammatory bowel disease or gastroparesis etc

Please give details*
Do you suffer with diabetes?*

For example: inflammatory bowel disease or gastroparesis etc

Are you taking Insulin?*
Please give details*
Do you suffer from any mental health problems?*

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

Please give details*
Do you suffer with an eating disorder?*

For example: anorexia, bulimia, binge eating etc.

Please give details*
Do you have any other medical problems?*

For example: anorexia, bulimia, binge eating etc.

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

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

Please list all medicines and what they treat*
Do you have any known allergies?*
Please list your allergies*
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.*
GP name
GP practice address
GP practice telephone number
GP practice email address

About your lifestyle

Do you smoke?*
How many per day?*
Do you drink alcohol?*
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

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)*
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 Mysimba, Saxenda, Wegovy, Ozempic or Phentermine?*
Which one, and how long have you been taking it?*

Declaration & Consent to Treatment

Kindly TICK to confirm that you agree with each of the following statements if you wish to proceed with treatment, then please sign your name below
How did you locate the consultation form?*
Please specify*

Readiness to change

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?*
How motivated are you to change your eating habits at this time?*
How motivated are you to increase your physical activity at this time?*
How motivated are you to try new strategies/techniques for changing your dietary, physical activity and other health related behaviors at this time?*
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?*
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?*
How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?*

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