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.
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
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
5
Ethnicity Qualifier Value
6
What's your height in cm?* This field is required.
Please enter in centimetres, not metres.
7
What's your weight in kg?* This field is required.
Please enter your weight in kg, not Ibs.
8
Calculated BMI
9
Required Qualifiers
10
Are you currently pregnant, breastfeeding, or planning on conceiving within the next 3 months?* This field is required.
Yes
No
11
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
12
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
13
What was the name of the medication?* This field is required.
14
What was your weight (kg) before starting your prescribed weight loss medication?* This field is required.
15
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
16
What dose were you prescribed most recently?* This field is required.
17
Did you experience any side effects or conditions while taking your weight loss medication?* This field is required.
Yes
No
18
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
19
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.
20
If you have proof of a previous prescription for weight loss medications, please upload here:
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Select files to upload
Max. file size: 10.6MB
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21
Do you wish to continue with the same weight loss medication?
Yes
No, I would like to try a different medication
22
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
23
GLP-1 History Qualifier Value
24
Some health problems can get better with weight loss. Have you ever been told you have any of these conditions, or any other health issues related to your weight?* 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
Other
Not sure
25
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)
26
Please provide further details of any other condition(s):* This field is required.
Huge
Large
Normal
Small
Ok
Ok
27
Comorbidities Qualifier Value
28
Some health conditions make certain weight-loss medications unsafe or unsuitable. Have you ever been told that you have any of the following conditions?* 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
Not sure
Other
29
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
30
Please provide further details of any other condition(s): * This field is required.
Huge
Large
Normal
Small
Ok
Ok
31
Do you currently have, or have a history of a mental health condition?* This field is required.
Yes
No
32
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
33
Please describe your mental health condition, whether it is currently stable, and how it is being treated* This field is required.
34
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
35
Have any of your first-degree relatives ever been diagnosed with thyroid cancer?* This field is required.
Yes
No
36
Do you have any other medical conditions?* This field is required.Your Partner Practitioner needs to know your full medical history to ensure your weight loss plan is safe and suitable for you.
Yes
No
37
Please describe any medical conditions you have, including those not mentioned above.* This field is required.
38
Are you taking any of the following medications?* This field is required.• Antidepressants • Insulin • Lithium • Hormonal Replacement Therapy (HRT) • Sulfonylureas • Warfarin
Yes
No
39
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
40
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.
41
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. Would you like to discuss this further with your Partner Practitioner?* This field is required.
Yes
No
42
Are you currently taking an oral contraceptive (birth control pill)?* This field is required.Your Partner Practitioner needs to know your full medical history to ensure your weight loss plan is safe and suitable for you.
Yes
No
43
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. Would you like to discuss this further with your Partner Practitioner?* This field is required.
Yes
No
44
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
45
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
46
Please provide details of these medications including name, dose, frequency, and reason for taking them.* This field is required.
47
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
48
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)
49
Do you have any other allergies or history of a severe drug reaction?* This field is required.Your Partner Practitioner needs to know your full medical history to ensure your weight loss plan is safe and suitable for you.
Yes
No
50
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.
51
Overall Qualifier Outcome
52
Final Eligibility Outcome
53
Based on the information you’ve provided, it may be that some weight-loss treatments may not be suitable for you right now. This isn’t a final decision and a Partner Practitioner can review your information and confirm what options (if any) are appropriate. You’re welcome to proceed to a consultation with a Partner Practitioner. If you choose to proceed, please note that the consultation fee will not be refundable.* This field is required.
I agree, and would like to proceed
54
Please let us know any treatment preferences you would like your UK-registered Partner Practitioner to consider: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.
55
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: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.
56
Please enter your full name* This field is required.
First Name
Last Name
57
Please enter your date of birth* This field is required.
Date
Day
Month
Year
58
Please enter your email address* This field is required.
example@example.com
Confirm Email
59
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60
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61
Do you have an NHS GP?* This field is required.If Yes - please provide the name of your NHS GP Surgery
Yes
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62
NHS Surgery
63
NHS NumberPlease leave blank if unsure or if you do not have an NHS number
64
Please upload your ID, passport, driver’s license, or work ID for identity confirmation* This field is required.
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65
Please upload recent photos of yourself to support clinical review* This field is required.These images help your Partner Practitioner confirm suitability and monitor treatment progress. • Photos should be recent • Please include front and side views • Wear fitted clothing
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66
By submitting your consultation request, you confirm that you agree to our Terms & Conditions and our Privacy Notice and you agree that:* This field is required.- Your request is not an emergency and you do not need urgent care. - This is a private clinical consultation. A prescription is not guaranteed. If prescribed, medication costs are extra and set by the dispensing pharmacy. - Any prescribing decision is made solely by your Partner Practitioner. - Your personal data (including your health data) will be shared with Partner Practitioners to support continuity of care. - All of the information you have provided is accurate and truthful..
I agree
67
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