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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Weight Loss 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.

1. Personal Details

First Name *
Last Name *
Phone Number *
Email *
Age *
Date of Birth (dd/mm/yyyy) *
Gender *

Your Address

House Number or Name *
Street Address *
City *
Post Code *
Country *

Your Weight

Select Weight Input *

Weight (ST) *
Weight (LBS) *

Weight (LBS) *
Weight (KG) *

Your Height

Select Height Input *

Height (FT) *
Height (IN) *

Height (CM) *

Your BMI + Blood Pressure Range

BMI *

What is your usual blood pressure range? *

2. 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 on Heart Problems *

Do you have any thyroid problems? (e.g. goiter, Graves' disease, hypothyroid, hyperthyroid) *
Please give details on Thyroid Problems *
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 on pancreatitis *
Do you suffer from any kidney problems? *
Please give details on Kidney problems *
Do you suffer from any liver problems? *
Please give details on Liver problems *
Do you suffer from any SEVERE gastro-intestinal problems? *
Please give details on Gastro Intestinal problems *

Do you suffer with diabetes? *
Are you taking Insulin? *
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 on mental health problems *
Do you suffer with an eating disorder? *
For example: anorexia, bulimia, binge eating etc.
Please give details on eating disorder *
Do you have any other medical problems? *
Please give details on medical problems *
Are you taking any other medication not already identified above? *
For example other prescribed medication, products purchased over-the-counter or herbal supplements
Please give other medication details *
Do you have any known allergies? *
Please list your allergies *

It is our policy to inform your GP... Please tick 'YES' below to give us your permission to do so. *
GP name *
GP practice address *
GP practice telephone number *
GP Email *

3. About Your Lifestyle

Do you smoke? *
How many per day? *

Do you drink alcohol? *
How many units per week? *

How many cups of tea or coffee each day? *
How many glasses of water each day? *
How many hours sleep per night? *
How much exercise per week? *

4. Your Weight-loss Journey

How many calories do you consume per day? *

Please describe your typical daily diet *

What contributes to your excess weight? (Tick all that apply) *

What weight loss interventions have you 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? *

5. Declaration & Consent

Tick to confirm you agree with the following: *

How did you locate the consultation form? *

6. Readiness to Change


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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