Weight Loss Consultation

1
How old are you?* This field is required.
Less than 18 years old
18-75 years old
Over 75 years old
2
What sex were you assigned at birth?* This field is required.
Male
Female
3
What is your ethnic background?* This field is required.
Please Select
Please Select
Black African or African-Caribbean
East or Southeast Asian
South Asian
Middle Eastern or North African
Latino or Hispanic
White
Mixed or multiple ethnic backgrounds
Other
Prefer not to say
4
Ethnicity Qualifier Value
5
What's your height in cm?* This field is required.
Please enter in centimetres, not metres.
6
What's your weight in kg?* This field is required.
Please enter your weight in kg, not Ibs.
7
Calculated BMI
8
Required Qualifiers
9
Are you currently pregnant, breastfeeding, or planning on conceiving within the next 3 months?* This field is required.
Yes
No
10
Have you ever taken any prescribed weight loss medications before?* This field is required.For example: • Wegovy / Ozempic / Rybelsus (Semaglutide) • Mounjaro / Zepbound (Tirzepatide) • Saxenda / Victoza / Nevolat (Liraglutide) • Alli / Xenical (Orlistat)
Yes
No
11
Please select which medication(s) you have taken before:* This field is required.
Wegovy / Ozempic / Rybelsus (Semaglutide)
Mounjaro / Zepbound (Tirzepatide)
Saxenda / Victoza / Nevolat (Liraglutide)
Alli / Xenical (Orlistat)
Other
12
What was the name of the medication?* This field is required.
13
What was your weight (kg) before starting your prescribed weight loss medication?* This field is required.
14
When did you last take this medication?* This field is required.
Less than 4 weeks ago
4-8 weeks ago
More than 8 weeks ago
15
What dose were you prescribed most recently?* This field is required.
16
Did you experience any side effects or conditions while taking your weight loss medication?* This field is required.
Yes
No
17
Please select all that apply:* This field is required.
Nausea
Vomiting
Severe constipation
Diarrhoea
Ongoing or severe abdominal (stomach) pain
Heartburn or acid reflux
Gallstone or gallbladder problems
Pancreatitis
Injection-site reactions
Other
18
Please describe the side effects you experienced (for example: how severe they were, how long they lasted, whether they went away, and if anything helped).* This field is required.
19
If you have proof of a previous prescription for weight loss medications, please upload here:
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20
Do you wish to continue with the same weight loss medication?
Yes
No, I would like to try a different medication
21
Which weight loss medication would you like to try?
Wegovy / Ozempic / Rybelsus (Semaglutide)
Mounjaro / Zepbound (Tirzepatide)
Saxenda / Victoza / Nevolat (Liraglutide)
Alli / Xenical (Orlistat)
I would like to discuss with my Partner Practitioner
22
GLP-1 History Qualifier Value
23
Do you currently have any of the following conditions that may improve with weight loss?* This field is required.• Type 2 diabetes • High blood pressure (hypertension) • High cholesterol • Obstructive sleep apnoea (OSA) • Polycystic ovary syndrome (PCOS) • Osteoarthritis • Depression • Fatty liver disease • Asthma • Acid reflux (GORD)
Yes
No
24
Please select which condition(s) you have:* This field is required.
Type 2 diabetes
High blood pressure (hypertension)
High cholesterol
Obstructive sleep apnoea (OSA)
Polycystic ovary syndrome (PCOS)
Osteoarthritis
Depression
Fatty liver disease
Asthma
Acid reflux (GORD)
25
Comorbidities Qualifier Value
26
Do you have, or have you ever been diagnosed with, any of the following conditions that could affect the safety of prescription weight loss medications?* This field is required.• Bowel obstruction or ileus • Diabetic eye disease (diabetic retinopathy) • Eating disorder (e.g. anorexia nervosa, bulimia nervosa, binge eating disorder) • Gallbladder disease (stones, infection, blockage, or recent surgery) • Gastroparesis (delayed stomach emptying) • Heart failure • Inflammatory bowel disease (Crohn's disease or ulcerative colitis) • Multiple endocrine neoplasia type 2 (MEN2) • Pancreatitis (inflammation of the pancreas) • Liver disease or cirrhosis • Kidney disease or end-stage kidney failure (e.g. polycystic kidneys, chronic kidney disease) • Thyroid cancer • Type 1 diabetes
Yes
No
27
Please select which condition(s) you have:* This field is required.
Bowel obstruction or ileus
Diabetic eye disease (diabetic retinopathy)
Eating disorder (e.g. anorexia nervosa, bulimia nervosa, binge eating disorder)
Gallbladder disease (stones, infection, blockage, or recent surgery)
Gastroparesis (delayed stomach emptying)
Heart failure
Inflammatory bowel disease (Crohn's disease or ulcerative colitis)
Multiple endocrine neoplasia type 2 (MEN2)
Pancreatitis (inflammation of the pancreas)
Liver disease or cirrhosis
Kidney disease or end-stage kidney failure (e.g. polycystic kidneys, chronic kidney disease)
Thyroid cancer
Type 1 diabetes
28
Do you currently have, or have a history of a mental health condition?* This field is required.
Yes
No
29
Please select which mental health condition you have a history of:* This field is required.
Anxiety
Bipolar disorder
Depression
Obsessive-compulsive disorder (OCD)
Personality disorder
Psychosis
Schizophrenia
Other
30
Please describe your mental health condition, whether it is currently stable, and how it is being treated* This field is required.
31
Do you feel that your mental health condition is currently stable, and do you have access to the support you need?* This field is required.
Yes
No
32
Have any of your first-degree relatives ever been diagnosed with thyroid cancer?* This field is required.
Yes
No
33
Do you have any other medical conditions?* This field is required.Your Partner Doctor needs to know your full medical history to ensure your weight loss plan is safe and suitable for you.
Yes
No
34
Please describe any medical conditions you have, including those not mentioned above.* This field is required.
35
Are you taking any of the following medications?* This field is required.• Antidepressants • Insulin • Lithium • Hormonal Replacement Therapy (HRT) • Sulfonylureas • Warfarin
Yes
No
36
Please select which medication(s) you are taking:* This field is required.Knowing what medications you take helps us check for potential interactions and ensure your weight loss treatment is safe.
Antidepressants
Insulin
Lithium
Hormonal Replacement Therapy (HRT)
Sulfonylureas
Warfarin
37
Please provide brief details for each medication you selected above, including the name, dose, reason for use, and any side effects or monitoring* This field is required.
38
Hormone Replacement Therapy: HRT is generally considered safe to use alongside prescription weight loss medications. However, starting a weight loss medication may affect how oral HRT is absorbed. We recommend discussing your treatment with your HRT provider, who can advise on alternative non-oral forms or increased monitoring to ensure your hormone therapy remains effective.* This field is required.
I understand
39
Are you currently taking an oral contraceptive (birth control pill)?* This field is required.Your Partner Doctor needs to know your full medical history to ensure your weight loss plan is safe and suitable for you.
Yes
No
40
Some prescription weight-loss medications may affect the absorption of oral contraceptives, particularly when starting or increasing the dose. You may need to use backup contraception during this time. We recommend discussing this with your contraceptive provider if you have any questions or concerns.* This field is required.
I understand
41
If you take birth control pills, please tell us whether you use any additional contraception and if you’ve had vomiting, diarrhoea, or missed pills recently that could affect how well the pill works.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
42
Do you take any other prescribed medications, over-the-counter medications, or supplements?* This field is required.Knowing what medications you take helps us check for potential interactions and ensure your weight loss treatment is safe.
Yes
No
43
Please provide details of these medications including name, dose, frequency, and reason for taking them.* This field is required.
44
Do you have allergies to any of the following?* This field is required.• Ozempic / Wegovy / Rybelsus (Semaglutide) • Saxenda / Victoza (Liraglutide) • Mounjaro / Zepbound (Tirzepatide) • Disodium phosphate or dihydrate • Propylene glycol • Phenol • Hydrochloric acid • Sodium hydroxide • Benzyl alcohol • Glycerol (glycerine)
Yes
No
45
Please select which allergy/allergies you have:* This field is required.
Ozempic / Wegovy / Rybelsus (Semaglutide)
Saxenda / Victoza (Liraglutide)
Mounjaro / Zepbound (Tirzepatide)
Disodium phosphate or dihydrate
Propylene glycol
Phenol
Hydrochloric acid
Sodium hydroxide
Benzyl alcohol
Glycerol (glycerine)
46
Do you have any other allergies or history of a severe drug reaction?* This field is required.Your Partner Doctor needs to know your full medical history to ensure your weight loss plan is safe and suitable for you.
Yes
No
47
Please provide details of your allergy / severe drug reaction, including the substance, type of reaction, severity, and how it was managed.* This field is required.
48
Overall Qualifier Outcome
49
Final Eligibility Outcome
50
Based on your answers so far, you may be suitable for further review by a UK-registered Partner Practitioner. Please let us know any treatment preferences you would like them to consider:* This field is required.Some individuals may be prescribed GLP-1 receptor agonist medications following review by a UK-registered Partner Practitioner. Examples of prescription GLP-1 medications your Partner Doctor may consider include: • Wegovy (semaglutide) A once-weekly injectable medicine that acts on the GLP-1 receptor. • Mounjaro (tirzepatide) A once-weekly injectable medicine that acts on both the GLP-1 and GIP receptors. These medicines are prescription-only, not suitable for everyone, and may cause side effects. The information below is used to understand your preference only and does not guarantee treatment or a specific medication. All prescribing decisions are made at the sole discretion of your Partner Practitioner.
Please Select
Please Select
Wegovy
Mounjaro
I'm unsure / No preference
51
Please enter your full name* This field is required.
First Name
Last Name
52
Please enter your date of birth* This field is required.Your Partner Doctor will need this to issue a prescription.
Date
Day
Month
Year
53
Please enter your email address* This field is required.
example@example.com
Confirm Email
54
Please enter your mobile number* This field is required.
55
Please enter your address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please Select
Afghanistan
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Angola
Anguilla
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Australia
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The Bahamas
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Brazil
Brunei
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Canada
Cape Verde
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Christmas Island
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Cuba
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Dominican Republic
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El Salvador
Equatorial Guinea
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Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
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The Gambia
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Netherlands
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Niue
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eSwatini
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Other
Country
56
Do you have an NHS GP?* This field is required.If Yes - please provide the name of your NHS GP Surgery
Yes
No
57
NHS Surgery
58
NHS NumberPlease leave blank if unsure or if you do not have an NHS number
59
Proof of Identification (Passport, Driver's Licence, etc)
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60
Please upload recent photos of yourself to support clinical review* This field is required.These images help your Partner Doctor confirm suitability and monitor treatment progress. • Photos should be recent • Please include front and side views • Wear fitted clothing
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61
By submitting your consultation request, you acknowledge that you have read and agree to our Terms & Conditions and our Privacy Notice. Additionally, you consent to the following:* This field is required.- Your weight management consultation is for a private clinical review. A prescription is not guaranteed, and if prescribed, the cost of any medication is not included and will be set by the dispensing pharmacy; - All prescribing decisions are at the sole discretion of your Partner Practitioner; - You are NOT experiencing a medical emergency, serious medical condition, or any condition which requires immediate or urgent treatment; - Your personal information (including health information) will be shared with all Partner Practitioners on the Updoc platform to enable continuity of care; - You confirm that you have understood all the questions in the questionnaire and that all information you have provided, and will provide, to Partner Practitioners is accurate and truthful; - Your Partner Practitioner may require that you provide additional information to ensure they have the full picture.
I agree
62
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