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 *MaleFemailWhat 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. Checkboxes 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?Dropdown Select your ethnicityWhiteBlackAfricanBlack/african/CaribbeanChineseIndianAsianPlease provide your height.Dropdown Feet & InchesCentimetersOption 3Dropdown 3 ft4 ft5 ft6 ft7 ft8 ftDropdown 0 in1 in2 in3 in4 in5 in6 in7 in8 in9 in10 in11 inPlease provide your weight.Select Weight Unit KilogramsStonesDropdown Select40 kg41 kg42 kgWhen did you last check your weight?When did you last check your weight? *2126212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719260102030405060708091011120102030405060708091011121314151617181920212223242526272829303132What is your target weight for the next 12 months?Select Weight KilogramsStonesDropdown Select40 kg41 kg42 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)?Multiple Choice YesNoDo you have any allergies?Multiple Choice 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?Multiple Choice 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 Multiple Choice YesNoEmailSubmit
