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Consultation Form
Jason Long
2024-05-23T08:16:27+01:00
Med Ali Ltd T/A SKYNDOCTOR
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1) About You
1.1) Name
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First name
Surname
1.2) Address
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House number or name
City
Postcode
1.3) Phone number
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1.4) Email Address
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1.5) Date of birth
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DD slash MM slash YYYY
1.5.1) Age
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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
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Female
Male
1.6.1) Are you pregnant, breastfeeding or trying to get pregnant?
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No
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.
1.7) Height
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1.7) Weight
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ST/LBS
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1.8) Height
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1.9) BMI
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1.8) Weight
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1.9) BMI
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Hidden weight kg
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1.10) What is your usual blood pressure range?
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Select from list
Low - 90/60 or Below
Normal - Between 91/61 and 139/89
High - 140/90 or Above
I dont know
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?
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For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.
Yes
No
Please give details
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2.2) Do you have any thyroid problems?
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For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.
Yes
No
Please give details
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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?
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Yes
No
Please give details
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2.4) Do you currently, or have you ever had pancreatitis?
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Yes
No
Please give details
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2.5) Do you suffer from any kidney problems?
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Yes
No
Please give details
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2.6) Do you suffer from any liver problems?
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For example: hepatitis, fatty liver, alcohol liver disease etc.
Yes
No
Please give details
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2.7) Do you suffer from any SEVERE gastro-intestinal problems?
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For example: inflammatory bowel disease or gastroparesis etc
Yes
No
Please give details
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2.8) Do you suffer with diabetes?
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Yes
No
2.8.1) Are you taking Insulin?
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Yes
No
Please give details
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2.9) Do you suffer from any mental health problems?
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For example: severe anxiety, severe depression, schizophrenia, personality disorders, body dysmorphia, thoughts of suicide etc.
Yes
No
Please give details
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2.10) Do you suffer with an eating disorder?
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For example: anorexia, bulimia, binge eating etc.
Yes
No
Please give details
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2.11) Do you have any other medical problems?
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Yes
No
Please give details
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2.12) Are you taking any other medication not already identified above?
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For example other prescribed medication, products purchased over-the-counter or herbal supplements
Yes
No
Please list all medicines and what they treat.
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2.13) Do you have any known allergies?
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Yes
No
Please list your allergies
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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.
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Yes
No
GP name
GP practice address
GP practice telephone number
GP practice email address
3) About your lifestyle
3.1) Do you smoke?
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Yes
No
How many per day?
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Select from list
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
40+
3.2) Do you drink alcohol?
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Yes
No
3.2.1) How many units per week? Copy and paste this link to calculate your units https://www.drinkaware.co.uk/sevendaycalculator
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Select from 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
.
3.3) How many cups of tea or coffee do you drink each day?
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Select from list
None
1 - 2
3 - 4
5 - 6
7 - 8
9 +
3.4) How many glasses of water do you drink each day?
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NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation
Select from list
None
1 - 2
3 - 4
5 - 6
7 - 8
9 +
3.5) How many hours of sleep do you average each night?
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Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.
Select from list
less than 4
5 - 6
7 - 8
8 +
3.6) How much exercise / activity do you do each week?
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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)
Select from list
Very little
One hour
Two to Three hours
More than Three hours
4) Your weight-loss journey
4.1) How many calories do you consume per day?
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Select from list
Less than 1000
1000-1500
1501-2000
2001-2500
More than 2500
4.2) Please describe your typically daily diet
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4.3) What contributes to your excess weight? (Please tick ALL that apply)
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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
Select All
4.4) Please tell us what weight loss interventions you have previously tried
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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?
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Yes
No
Which one, and how long have you been taking it?
*
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
I have answered all questions truthfully, and I am aware that It is a criminal offense to give false or misleading information about my health
I am over the age of 18
This prescription request is for my own personal use
I will read the patient information leaflet supplied
I agree to follow the dosing schedule prescribed
I am aware that I must combine treatment with a reduced calorie diet and increased physical activity for best results
I agree to record my daily food intake and physical activity
I am aware that there are no guarantees of weight loss using any of these treatments
I understand that if I have not lost 5% of my initial body weight after 12 weeks of being on the licensed dose, I must discontinue treatment
I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment
Should I experience any changes in my medical history, I will immediately inform the clinic
Select All
Patient Signature
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5.2) How did you locate the consultation form?
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Website link
Facebook link
Instagram link
Link in an email we sent
Link in a message we sent
Through a friend
Other
Please specify
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Date
*
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?
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0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
6.2) How motivated are you to change your eating habits at this time?
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0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
6.3) How motivated are you to increase your physical activity at this time?
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0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
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?
*
0 : Not at all motivated
1 : Slightly motivated
2 : Somewhat motivated
3 : Quite motivated
4 : Extremely motivated
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?
*
0 : Not at all confident
1 : Slightly confident
2 : Somewhat confident
3 : Quite confident
4 : Extremely confident
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?
*
0 : Not at all confident
1 : Slightly confident
2 : Somewhat confident
3 : Quite confident
4 : Extremely confident
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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0 : Not at all satisfied
1 : Slightly satisfied
2 : Somewhat satisfied
3 : Quite satisfied
4 : Extremely satisfied
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