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Consultation FormJason Long2025-01-27T16:16:10+00:00

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Step 1 of 6 - About you

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1) About You

1.1) Name*
1.2) Address*
DD slash MM slash YYYY
You must be aged between 18 - 75 to use our service. If you need to speak to a healthcare professional about treatment, please arrange to see your GP.
1.6) Gender*
1.6.1) Are you pregnant, breastfeeding or trying to get pregnant?*
This treatment is not suitable if you are pregnant, trying to get pregnant or breastfeeding. We recommend you speak to your GP in person.
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Weight & Height
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2) About your Health

Please be aware that it is important to give truthful information about your medical history.
2.1) Do you suffer from any heart problems?*
For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.
2.2) Do you have any thyroid problems?*
For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.
Losing weight and keeping it off can be a struggle, especially if you have an under-active thyroid. Please ensure you have regular bloods taken with your GP to ensure you are taking the correct dose of thyroxine.
2.3) Have you, or anyone in your immediate family ever had thyroid cancer?*
2.4) Do you currently, or have you ever had pancreatitis?*
2.5) Do you suffer from any kidney problems?*
2.6) Do you suffer from any liver problems?*
For example: hepatitis, fatty liver, alcohol liver disease etc.
2.7) Do you suffer from any SEVERE gastro-intestinal problems?*
For example: inflammatory bowel disease or gastroparesis etc
2.8) Do you suffer with diabetes?*
2.8.1) Are you taking Insulin?*
2.9) Do you suffer from any mental health problems?*
For example: severe anxiety, severe depression, schizophrenia, personality disorders, body dysmorphia, thoughts of suicide etc.
2.10) Do you suffer with an eating disorder?*
For example: anorexia, bulimia, binge eating etc.
2.11) Do you have any other medical problems?*
2.12) Are you taking any other medication not already identified above?*
For example other prescribed medication, products purchased over-the-counter or herbal supplements
2.13) Do you have any known allergies?*
2.14) 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.*

3) About your lifestyle

3.1) Do you smoke?*
3.2) Do you drink alcohol?*
Excessive alcohol consumption can increase the risk of serious health issues. To get help with cutting down drinking, visit this page.
NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation
Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.
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)

4) Your weight-loss journey

4.3) What contributes to your excess weight? (Please tick ALL that apply)*
For example: weight watchers, slimming world, increased exercise, went to see GP, medication etc
4.5) Are you currently taking any weight loss treatments such as Mysimba, Saxenda, Wegovy, Ozempic or Phentermine?*

5) Declaration & Consent to Treatment

5.1) 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
5.2) How did you locate the consultation form?*
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DD slash MM slash YYYY

6) 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.
6.1) Do you feel motivated to lose weight at this time?*
6.2) How motivated are you to change your eating habits at this time?*
6.3) How motivated are you to increase your physical activity at this time?*
6.4) How motivated are you to try new strategies/techniques for changing your dietary, physical activity and other health related behaviors at this time?*
6.5) 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?*
6.6) 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?*
6.7) 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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