Weight Loss Weight Loss Your Personal Details Please kindly fill in your name, email and phone number. We need to know this information so we can ask relevant clinical questions, define our communication channels and recommend suitable treatments. First Name *Email Address *House Number *City *Last Name *Phone Number *Address *Post-Code *What was your assigned sex at birth? This online consultation depends on knowing your assigned sex at birth, not your gender identity. We need to know this information so we can ask relevant clinical questions and recommend suitable treatments.What was your assigned sex at birth *MaleFemaleWhat is your date of birth?What is your date of birth? *2126212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719260102030405060708091011120102030405060708091011121314151617181920212223242526272829303132Do you confirm that: You understand that it is in your best interests to answer all questions in full, providing accurate and honest information. You are using this service yourself, of your own free will, and any medicine is for your personal use only. You have the capacity to understand all about the condition and medication information we have provided in advance, and you give fully informed consent to the treatment option provided in your best interests. You have read and fully understand what this medicine is used for, as well as all the possible treatment options for your condition, and are aware of all the possible benefits, risks, or side effects. You agree to read the patient information leaflet before taking any medicine and use the medication only as directed. Do you confirm that: I confirmPeople of certain ethnicities may be suitable for treatment at a lower BMI than others, if appropriate. Do any of the following apply to you?Ethnicity Select your ethnicityWhiteBlackAfricanBlack/african/CaribbeanChineseIndianAsianPlease provide your height.Height Feet 3 ft4 ft5 ft6 ft7 ft8 ftHeight Inches 0 in1 in2 in3 in4 in5 in6 in7 in8 in9 in10 in11 inPlease provide your weight.Weight Select40 kg41 kg42 kg43 kg44 kg45 kg46 kg47 kg48 kg49 kg50 kg51 kg52 kg53 kg54 kg55 kg56 kg57 kg58 kg59 kg60 kg61 kg62 kg63 kg64 kg65 kg66 kg67 kg68 kg69 kg70 kg71 kg72 kg73 kg74 kg75 kg76 kg77 kg78 kg79 kg80 kg81 kg82 kg83 kg84 kg85 kg86 kg87 kg88 kg89 kg90 kg91 kg92 kg93 kg94 kg95 kg96 kg97 kg98 kg99 kg100 kg101 kg102 kg103 kg104 kg105 kg106 kg107 kg108 kg109 kg110 kg111 kg112 kg113 kg114 kg115 kg116 kg117 kg118 kg119 kg120 kg121 kg122 kg123 kg124 kg125 kg126 kg127 kg128 kg129 kg130 kg131 kg132 kg133 kg134 kg135 kg136 kg137 kg138 kg139 kg140 kg141 kg142 kg143 kg144 kg145 kg146 kg147 kg148 kg149 kg150 kg151 kg152 kg153 kg154 kg155 kg156 kg157 kg158 kg159 kg160 kg161 kg162 kg163 kg164 kg165 kg166 kg167 kg168 kg169 kg170 kg171 kg172 kg173 kg174 kg175 kg176 kg177 kg178 kg179 kg180 kgWhen did you last check your weight?When did you last check your weight? *2126212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719260102030405060708091011120102030405060708091011121314151617181920212223242526272829303132What is your target weight for the next 12 months?Target weight for the next 12 months Select40 kg41 kg42 kg43 kg44 kg45 kg46 kg47 kg48 kg49 kg50 kg51 kg52 kg53 kg54 kg55 kg56 kg57 kg58 kg59 kg60 kg61 kg62 kg63 kg64 kg65 kg66 kg67 kg68 kg69 kg70 kg71 kg72 kg73 kg74 kg75 kg76 kg77 kg78 kg79 kg80 kg81 kg82 kg83 kg84 kg85 kg86 kg87 kg88 kg89 kg90 kg91 kg92 kg93 kg94 kg95 kg96 kg97 kg98 kg99 kg100 kg101 kg102 kg103 kg104 kg105 kg106 kg107 kg108 kg109 kg110 kg111 kg112 kg113 kg114 kg115 kg116 kg117 kg118 kg119 kg120 kg121 kg122 kg123 kg124 kg125 kg126 kg127 kg128 kg129 kg130 kg131 kg132 kg133 kg134 kg135 kg136 kg137 kg138 kg139 kg140 kg141 kg142 kg143 kg144 kg145 kg146 kg147 kg148 kg149 kg150 kg151 kg152 kg153 kg154 kg155 kg156 kg157 kg158 kg159 kg160 kg161 kg162 kg163 kg164 kg165 kg166 kg167 kg168 kg169 kg170 kg171 kg172 kg173 kg174 kg175 kg176 kg177 kg178 kg179 kg180 kgHave you previously taken any medicine to help with weight loss?Have you previously taken any medicine to help with weight loss? YesNoHow many calories do you think you consume daily?Have you previously taken any medicine to help with weight loss? (copy) Less than 15001500 - 20002000 - 30003000 - 4000More than 4000I know the exact amountI don't count caloriesAre you comfortable using an injection pen?Are you comfortable using an injection pen? YesNoPlease upload a full body picture of yourself. We will only ask for this every 6 months. The picture will only be visible to you and the doctor. We realise it’s inconvenient, but it’s for the safety of our patients, and to prevent health risks in those who are vulnerable. Tip: use a full length mirror Upload picture: Drop your file here or click here to upload You can upload up to 1 files. Maximum allowed file size is 10mb.Have you been diagnosed with high blood pressure (with or without treatment)?High blood pressure YesNoDo you have any allergies?Allergies YesNoHave you ever had any medical conditions or surgery not previously mentioned in this form, or is there any further information you would like to provide the doctor?Any medical conditions or surgery YesNoDo you have any of the following weight-related conditions? Asthma Chronic back pain Fatty liver disease Gallbladder disease Heart disease (this includes high cholesterol, heart attack, stroke, coronary artery disease) Osteoarthritis or gout Polycystic Ovarian Syndrome (PCOS) Sleep apnea Weight-related conditions YesNoNameSubmit
