Medicated Weight Loss Consultation

What is your current weight? *

This is so we can work out your BMI. Please note: We must be able to verify your weight before prescribing any treatment either through a video call or home/clinic visit

Kilograms (kg)

Stone & pounds

kg

What is your current height? *

This is so we can work out your BMI. Please note: We must be able to verify your height before prescribing any treatment either through a video call or home/clinic visit

Centimetres (cm)

Feet & inches

cm

Have you received advice from a weight management counsellor before or previously taken any weight loss medication (e.g Orlistat, Alli, Xenical or phentermine)? *

Yes No

Please provide more information on what weight loss programme you did and/or what medication you took

Have you tried to manage your weight by altering your diet and increasing physical activity? *

Yes No

Please can you provide more information on the types of exercise and diet changes you have made, and whether this has worked effectively or not?

Do you suffer from Diabetes (Type 1 or 2) or Pre-Diabetes? *

Type 1 Diabetes Type 2 Diabetes Pre-diabetic I do not have Diabetes

What was your latest blood pressure reading? *

Have you ever had an allergic reaction to Saxenda, Wegovy, Liraglutide, Semaglutide or you have any other allergies we should be aware of? *

Yes No

Please provide more details on all allergies you have

Regarding your medical conditions, do you currently have or suffer from any of the following? *

You can select multiple options if required

Inflammatory bowel disease including Crohns Disease and Colitis Any other disorders of the stomach (e.g Ulcers or Gastritis) Cardiovascular problems including stroke or heart attack Fast heart rate (Tachycardia) Liver or kidney problems Polycystic Ovary Syndrome (PCOS) Diabetic retinopathy/Diabetic eye disease Pancreatitis Gallstones Cholestasis Chronic malabsorption syndrome Mental health problems (including anxiety, depression, bipolar or have suicidal thoughts) Eating disorder (e.g anorexia or bulimia) None of the above

Do you suffer from any of the following medical conditions? *

You can select multiple options if required

Dysglycaemia (Abnormal sugar levels) Hypertension (High blood pressure) Dyslipidaemia (High Cholesterol) Obstructive sleep apnoea Asthma/Chronic obstructive pulmonary disease (COPD) Thyroid cancer or a family history of thyroid cancer Erectile Dysfunction None of the above

Are you currently taking or have recently finished taking (in the last month) any medication, whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs? *

Yes No

Please provide an update list of all medications whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs that you are taking or have recently stopped taking

Are you breastfeeding, pregnant, or possibly pregnant? *

If you are Male, please select No

Yes No

Have you ever had surgery or is there any other medical or non-medical information we should be aware of? *

Yes No

Please provide more details

Before you continue

Please read the following statements:

DISCLAIMER ABOUT THIS TREATMENT: It is important to maintain a good level of hydration to avoid suffering from dehydration. I understand I must have my blood pressure checked regularly whilst taking this medication. Weight Loss Injections must be used in conjunction with ongoing lifestyle changes of a reduced calorie diet and increased physical exercise. I understand there have been rare cases of patients developing inflammation of the pancreas whilst taking Saxenda/Wegovy. I will stop taking the medication immediately if I experience any of the following serious side effects: Abdominal pain that radiates to my back, Abdominal pain that feels worse after eating, Fast heartbeat, Vomiting, Yellowing of the skin and eyes (Jaundice), Fever. I understand how to administer injected weight loss medication subcutaneously. Details on how to administer the medication can be found at the following link: https://youtu.be/B1kldLAX2uk. I understand that my order will be reviewed by a Prescriber and I must book either a video call or a free home visit to verify my BMI before my order can be approved. This medication is subject to additional monitoring requirements by the Medicines and Healthcare Products Regulatory Agency (MHRA) and so any side effects must be reported to them via the Yellow Card Scheme. All used needles should be placed in the sharps bin (which is provided free of charge on request when ordering medication from us) and disposed of safely. This can be disposed of at a local Pharmacy offering a needle exchange service, at your GP practice, or by contacting your local council.
DISCLAIMER GENERAL: I confirm these questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health. I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from Pharmacy. I confirm I will take the medication as prescribed or directed for its intended use. I have read or will read the patient information leaflet and I will contact a medical professional if I have any questions or experience any side effects while taking the medication. All information provided will be handled in the strictest confidence in line with GDPR regulations. I am happy for Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition. I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist.

I agree to all of the above statements