Weight Loss Questionaire

Step 1 of 16

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.

Your details

Name*

First Last

Phone*

Email*

Age*

Date of Birth*

DD slash MM slash YYYY

Untitled*

Date

MM slash DD slash YYYY

Your address

Address*

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

Your height

Preferred Unit System

Metric

Imperial

Meters

Centimeters

Feet

Inches

Your weight

Preferred Weight Unit System

Metric (kg/g)

Imperial (Stone/lbs)

Kilograms

Grams

Stone

Pounds

Blood pressure

What is your usual blood pressure range?*

Do you suffer from any heart problems?*

For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.

Please detail*

Do you have any thyroid problems?*

For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.

Please detail*

Have you, or anyone in your immediate family ever had thyroid cancer?*

Please detail*

Do you currently, or have you ever had pancreatitis?*

Please detail*

Do you suffer from any kidney problems?*

Please detail*

Do you suffer from any liver problems?*

For example: hepatitis, fatty liver, alcohol liver disease etc.

Please detail*

Do you suffer from any severe gastro-intestinal problems?*

For example: inflammatory bowel disease or gastroparesis etc

Please detail*

Do you suffer with diabetes?*

Please detail*

Do you suffer from any mental health problems?*

For example: severe anxiety, severe depression, schizophrenia, personality disorders, body dysmorphia, thoughts of suicide etc.

Please detail*

Do you suffer with an eating disorder?*

For example: anorexia, bulimia, binge eating etc.

Please detail*

Do you have any other medical problems?*

Please detail*

Are you taking any other medication not already identified above?*

For example other prescribed medication, products purchased over-the-counter or herbal supplements

Please detail*

Do you have any known allergies?*

Please detail*

Your GP Details

Patient Notice: 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 'I Agree' below to give us your permission to do so.

GP Name*

GP Phone Number*

Your GP Address Details*

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

I Agree*

I agree on Pharma Aesthetics Contacting My GP

Do you smoke*

How many per day?*

Smoking increases the risk of serious health issues. You can find more information about quitting here.

Do you drink alcohol?*

How many units per week?*

To calculate alcohol consumption,visit here.

Excessive alcohol consumption can increase the risk of serious health issues. To get help with cutting down drinking,visit here.

This field is hidden when viewing the form

How many cups of tea or coffee do you drink each day?*

This field is hidden when viewing the form

How many glasses of water do you drink each day?*

NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation

How many hours of sleep do you average each night?*

Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.

How much exercise / activity do you do each week?*

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)

Your weight loss journey!

How many calories do you consume per day?*

Please describe your typically daily diet*

What contributes to your excess weight? (Please tick ALL that apply)*

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

Please tell us what weight loss interventions you have 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 Xenical, Alli, Mysimba, Saxenda, Ozempic, Wegovy, Mounjaro or Phentermine?*

Which one, and how long have you been taking it?*

Declaration & Consent

I confirm that I have answered all the above questions truthfully*

I Confirm

Should I experience any changes in my medical history, I will immediately inform the clinic*

I Confirm

I understand that any weight loss treatment MUST be used in conjunction with a reduced calorie diet, and increased physical activity for best results.*

I Confirm

I agree to record my daily food intake and physical activity*

I Confirm

I agree to follow the guidelines provided*

I Confirm

I confirm that no guarantees for weight loss have been given, and that results will vary from individual to individual. I am also aware that around 1 - 2% of people do not respond to treatment, but the reason for this is unknown, and I accept this possibility*

I Confirm

I agree to read the patient leaflet before starting the Pen*

I Confirm

I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment*

I Confirm

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.

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.

Do you feel motivated to lose weight at this time?*

0 : Not at all motivated

1 : Slightly motivated

2 : Somewhat motivated

3 : Quite motivated

4 : Extremely motivated

How motivated are you to change your eating habits at this time?*

0 : Not at all motivated

1 : Slightly motivated

2 : Somewhat motivated

3 : Quite motivated

4 : Extremely motivated

How motivated are you to increase your physical activity at this time?*

0 : Not at all motivated

1 : Slightly motivated

2 : Somewhat motivated

3 : Quite motivated

4 : Extremely motivated

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

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

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

How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?*

0 : Not at all satisfied

1 : Slightly satisfied

2 : Somewhat satisfied

3 : Quite satisfied

4 : Extremely satisfied

Name

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

Online Pharmacy

Mens Health

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General Health

Initial Assessment Form

Medical Questionnaire

Your details

Your address

Your height

Your weight

Blood pressure

Your GP Details

Your weight loss journey!

Declaration & Consent

Readiness to change

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