Complete our short questionnaire if you want to: begin weight loss treatment reorder your current medication Our team will check your details and prescribe treatment, if this is suitable. Weight loss treatments You can start weight loss medication if you meet the criteria for taking it. This usually involves having a certain body mass index (BMI) or weight-related health conditions, but each type of weight loss medication has different criteria. Most medications require a prescription, except alli which you can get over the counter, although a pharmacist or doctor still needs to check your suitability. When you take weight loss medications, you should commit to a low-calorie diet and regular exercise. These medical questions help our team treat you safely. Check that you fully understand them, and message us if you're unsure. Name Last Name Email Address Phone number Home Address About you Please enter your height. We need this so we can calculate your body mass index (BMI) accurately. If you don’t know this, please measure yourself before continuing. Please ensure that you add the correct figures as any false or inaccurate information may lead to severe illness and serious harm. In cm Medication Are you currently using any weight loss medication? This includes tablets or injections that we’ve been prescribing for you, or ones you're getting from another provider. Yes No BMI Please enter your current weight. We need this so we can calculate your body mass index (BMI) accurately. If you don’t know this, please weigh yourself before continuing. Please ensure that you add the correct figures as any false or inaccurate information may lead to severe illness and serious harm. Weight in kg How would you describe your ethnic background? What’s considered a healthy weight can be different depending on your ethnic background. Tell us how you describe yourself so we can ensure you’re getting the right care. I'd prefer not so say Asian or Asian British ( includes mixed Asian, Pakastani, Bangladesh, Chinese Black, Black Bristish, Caribbean, African (includes mixed Black) Middle Eastern White (includes English, Welsh, Scottish, Northern Irish or British) None of the above Your medical history Do you have any of these conditions? Diabetes Pre-diabetes High bloodpressure (hypertension) High cholestrol Obstructive sleep apnoea (OSA) No, none of these Have you ever had an eating disorder? For example, bulimia or anorexia. If you think you may have an eating disorder, but have never been diagnosed, please select ‘yes’. Yes No Are you currently pregnant, breastfeeding, or trying to get pregnant? Yes No Are there any other significant illnesses or medical conditions that you haven’t mentioned already? This could be a current or past condition. Yes No Do you currently take any medication, or have you recently finished a course of medication, that you haven't mentioned already? This includes medication you take occasionally or in emergencies. Yes No Are you allergic to any medicines or other substances? For example, peanuts, soya, or other medications (including weight loss medications you’ve previously used). Yes No Your GP Are you currently registered with a UK GP practice? Yes No I don't know Important information to review Please read the following, and confirm that you understand and agree. Select all options to agree You must let us know if your medical situation changes or if you start a different medication before beginning treatment with us. Just send us a message via email to [email protected] Our team will take your BMI and all of your medical history into consideration and may prescribe off-label when making a decision about treatment. Prescribed weight loss medication is only effective alongside other important lifestyle changes. For example, eating a low calorie diet and increasing physical activity. If I don't make these changes, I may lose less weight than expected (or none at all) and have to stop treatment altogether. This medication is for my personal use only. I understand and have answered the questions above honestly. I understand the side effects and effectiveness of these treatment options. This includes any alternative options available. What photos may you require? Photo 1: Feet on scales showing weight & date Make sure your weight is clearly readable on the scales Include a piece of paper with the current date written on it by hand Photo 2: Full body shot from the side with date Hold a piece of paper with the same handwritten date as photo 1 Your entire side profile must be visible You should wear fitted clothes that clearly show your figure Photo 3: Full body shot from the front with datei Hold a piece of paper with the same handwritten date as photos 1 and 2 Your entire front profile must be visible You should wear the same fitted clothes as photo 2 that clearly show your figure 0 + 1 =
