Weight Loss Assessment | Pharma Aesthetics

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Weight Loss Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Weight Loss Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Have you been actively trying to lose weight through diet and exercise without seeing significant results?*

Yes

No

Please provide more information below.*

Do you often feel hungry, even shortly after eating a meal?*

Yes

No

Please provide more information below.*

Have you experienced rapid weight gain over the past year without a clear reason?*

Yes

No

Please provide more information below.*

Do you find it difficult to control your portion sizes or resist high-calorie foods?*

Yes

No

Please provide more information below.*

Are you concerned that your weight is affecting your overall health or mobility?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medications that could be contributing to weight gain or hindering weight loss, such as steroids or antidepressants?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any pre-existing medical conditions, like thyroid disorders, diabetes, or cardiovascular diseases, that could influence your weight loss strategy?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you previously tried any weight loss medications, and did you experience any side effects?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant, planning to become pregnant, or breastfeeding, as this may impact the suitability of prescribed weight loss treatments?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any known allergies or sensitivities to common ingredients found in weight loss supplements or medications?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions are designed to provide a comprehensive overview of the patient's current situation and health status, which is crucial for safely prescribing effective weight loss treatments.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Email

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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