Weight Care

Are you between 18 and 75 years of age?*

What is your height (m)?*

What is your weight (kg)?*

BMI*

What is your waist circumference (cm)?*

What is your heart rate (beats per minute)?*

What is your ethnicity?*

Do you have any of the following conditions?*

• Prediabetes
• Heart disease
• High blood pressure
• High cholesterol
• Obstructive sleep apnoea

Have you ever had an allergic reaction to Wegovy, Semaglutide, Mounjaro, Tirzepatide, Saxenda, Liraglutide, Orlistat, Xenical, or their excipients listed in the SPC?*

Do you suffer from any of the following?*

• Type 1 & 2 Diabetes
• Diabetic gastroparesis
• Inflammatory bowel disease
• Ketoacidosis
• Obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain
• Severe renal impairment
• Severe hepatic impairment
• Pancreatitis
• Cholelithiasis and cholecystitis (include history), Gall bladder problems or gallstones
• Thyroid disease or medullary thyroid cancer (include history)
• Any eating disorders
• Heart Failure
• Sustained increase in resting heart rate
• Severe gastrointestinal disease, e.g. severe gastroparesis, chronic malabsorption syndrome
• Had bariatric surgery in last 12 months

If female: Are you currently pregnant?*

If female: Are you currently breastfeeding?*

Are you currently trying to conceive?*

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?*

Are you taking any of the following medications?*

• Amiodarone
• Carbamazepine
• Ciclosporin
• Clozapine
• Digoxin
• Lithium
• Iodine salts and/or Levothyroxine
• Oral Methotrexate
• Oral contraceptives
• Phenobarbital
• Phenytoin
• Tacrolimus
• Theophylline
• Warfarin
• Medications that treat HIV
• Medications that lower blood glucose
  • Acarbose
  • Alogliptin
  • Canagliflozin
  • Dapagliflozin
  • Dulaglutide
  • Empagliflozin
  • Ertugliflozin
  • Exenatide
  • Fenfluramine
  • Glibemclamide
  • Gliclazide
  • Glimepiride
  • Glipizide
  • Insulins
  • Linagliptin
  • Liraglutide
  • Lixisenatide
  • Metformin
  • Nateglinide
  • Pioglitazone
  • Repaglinide
  • Saxagliptin
  • Sitagliptin
  • Somatrogon
  • Tolbutamide
  • Vildagliptin
• Fat soluble vitamins (A, D, E and K)
• Medications that treat epilepsy

Are you taking any weight loss medications (i.e. Orlistat, Mysimba, GLP-1 receptor agonists: Wegovy, Mounjaro, Semaglutide, Saxender or Liragluride)?*

What is your specific weight-loss goal, how much weight do you aim to lose, and by when would you like to achieve it?*

Are you currently taking any GLP-1 receptor agonists?*

If you have previously started treatment or got the supply elsewhere, please upload proof of previous use. Documents may include a prescription, dispatch note, label, or receipt, and must clearly show:*

• Order Date/ Prescription Date/ Dispatch Date (required to be in the last 4 weeks)
• Medication name and dosage
• Patient name or email address

Please provide the start date of GLP-1 treatment ?*

Weight (kg):*

Height (m):*

BMI:*

Name of medication:*

Dose:*

Have you experienced any of the following side effects?*

• Gastro-Intestinal side effects e.g. nausea, vomiting, diarrhoea, constipation, bloating, reflux or heartburn
• Injection site reaction e.g. swelling, itching or redness
• Allergic reaction e.g. rash, itching
• Acute pancreatitis
• Bowel obstruction
• Gall bladder problems or gall stones
• Dehydration

Have you been appropriately titrated on the medication in line with the relevant Summary of Product Characteristics (SPC) or protocol, and are you following the correct injection schedule?*

Is there a gap (not using the medication more than 4 weeks) in the continuity of your medication supply?*

Have you already had a video consultation with one of our clinicians for weight loss treatment?*

When would you want to upload photos?*

Please upload a clear photo following these instructions:*

• Take a full-body, front-facing photo (head to toe if possible, minimum head to hips).
• Stand relaxed, facing forward with arms by your sides and feet shoulder-width apart (no face-only selfies).
• Use a plain background with good lighting, no glare or obstructions.
• Wear one layer of fitted clothing so your body shape is visible.

Do you understand that a video consultation with our clinician is required before we can supply your first weight loss treatment, and that future supplies only require updated photos unless our prescriber advises otherwise?*

Do you understand that GLP-1 injectable weight-loss medication (e.g. Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional contraceptive measures, such as a barrier method (e.g. condoms), or switching to a non-oral form of contraception (e.g. IUD’s and implants) for 4 weeks after initiating Mounjaro and for 4 weeks following each dose increase.*

Do you understand that GLP-1 injectable weight-loss medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?*

Do you understand the risk of pancreatitis, gall bladder issues, and gallstones associated with these medications, and that abdominal pain should be reported to a doctor?*

Do you understand that injectable weight-loss medications should not be used in combination with other weight-loss drugs?*

Do you understand that if you develop neck lumps or a hoarse voice while using this medication, you should stop and contact your doctor?*

Do you understand both weight loss and injectable weight loss treatment have been associated with lowering of mood, if experiencing depression, thoughts of self harm or other mental health issues should seek medical advice?*

Can we share this information with your General practitioner? Providing us with your physician\'s address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We would require you share this treatment with your doctor for him/her to update your medical records.*

Do you agree to the following?*

• You are aware that GLP-1 receptor agonists can lower your blood sugar, increasing the risk of hypoglycemia
• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
• You will inform your doctor about any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication and understands the titration schedule, actions to take if a dose is missed, correct self-injection technique, and proper storage requirements for the medication
• You will not exceed the maximum prescribed dose
• You understand that you should follow up with your GP at least once annually for ongoing monitoring and care
• You confirm you have the capacity to make decisions about your own health