form page nowe Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 11What is your date of birth? *NextWhat is your ethnicity? *Asian / Asian BritishBlack / Black British / Caribbean or AfricanMixed / Multiple Ethnic GroupsOther Ethnic Group (Please Specify)WhitePreviousNextWhat is your gender? *MaleFemalePreviousNextUnit SystemImperialMetricHeight *Height *Weight *Weight *HeightWeight BMI --- Underweight Potential weight loss * __ kg New target weight: __ kg PreviousNextHave you ever been diagnosed with diabetes? *YesNoMultiple Choice *Type 1Type 2PreviousNextHave you been diagnosed with any of the following? Eating disorder or history of disordered eating Gastrointestinal disorders Pancreatitis Active gallstones or cholestasis Liver health issues Kidney disease Respiratory health issues Cardiovascular disease High cholesterol (dyslipidemia) Cancer Bone/joint health issues History of surgery Mental health concerns Men's health issues select which one *YesNoPlease confirm if you have had any of the following: *Select if applicableEating disorder or history of disordered eatingGastrointestinal disorders *Select if applicableInflammatory bowel diseaseCoeliac diseaseChronic malabsorption syndromeGastro-oesophageal reflux disease (GORD) Pancreatitis *Select if applicableAcute pancreatitisCoeliac diseaseChronic pancreatitisHistory of pancreatitisActive gallstones or cholestasis *Select if applicableActive gallstones or CholestasisLiver health issues *Select if applicableNon-Alcoholic Fatty Liver Disease (NAFLD)Non-Alcoholic Steatohepatitis (NASH)1/2Fatty liver diseaseKidney disease *Select if applicableAcute Kidney Injury (AKI)Respiratory health issues *Select if applicableCOPD/asthmaSleep apnoeaObesity hypoventilation syndrome or Pickwickian syndromeCardiovascular disease *Select if applicableHypertensionVenous stasis diseaseSevere heart failureHigh cholesterol (dyslipidemia) *Select if applicableHigh cholesterol (dyslipidemia)Cancer *Select if applicableCurrent or history of pancreatic cancerFamily history of pancreatic cancerMedullary thyroid cancer or family history of itMultiple EndocrineNeoplasia syndrome type 2 (MEN 2)Neuroendocrine tumors (history of)Gallbladder cancer or active gallstonesBone/joint health issues *Select if applicableOsteoarthritisAches and painsChronic severe back painHistory of surger *Select if applicableThyroid surgeryBariatric operation (sleeve surgery, gastric band)Mental health concerns *Select if applicableLow moodWeight related anxietyDiagnosed with mental health conditionMen health issues *Select if applicableErectile dysfunctionLow testosterone Checkboxes Liver Layout PreviousNextDo you have any other medical conditions that have not been listed? *YesNoIt is crucial that our prescribers know your full medical history to ensure our weight loss plan is safe for you to start . Please tell us about any other medical conditions you have . *PreviousNextHave you previously taken, or are taking, any of the following weight loss medication? Mounjaro Wegovy Ozempic Saxenda Alli MySimba Multiple Choice *YesNoMultiple Choice *MounjaroWegovyOzempicSaxendaAlliMySimbaOtherPreviousNextDo you currently take any medication or have any allergies that you have not yet disclosed in this form? *YesnoPlease select any of the following statements that apply to you: *Prescribed MedicationI have allergiesI don't take medicationsBoth prescribed medication and allergiesPlease list any prescribed medications you are currently taking.Please clearly list your medications and allergies that you have, and describe any reactions you have experienced.Please clearly list your medications and allergies that you have, and describe any reactions you have experienced PreviousNext Please confirm you have read and agree to the following statements: I have personally completed this medical consultation. All answers provided are honest, accurate, and to the best of my knowledge. I have disclosed all prescription medications that I am currently taking. I will not take this medication alongside any other weight-loss medication. I have disclosed all relevant medical conditions, allergies, serious illnesses, and past surgeries. I confirm that I will be the sole user of any medication prescribed through this service. I understand that I may be prescribed off-label treatment. I agree to my details and prescription being shared with our pharmacy or a partner pharmacy for dispensing and delivery. I consent to relevant medical information being shared with my GP if clinically necessary to ensure safe prescribing. I will use the medication only as prescribed and will read the Patient Information Leaflet provided. I will inform the service provider if anything changes regarding my health, medications, or medical history. I accept the service's Terms of Sale and Privacy Policy. Checkboxes *I confirm that I have read, understood, and accept all the above statements.PreviousNextYour Recommended Weight Loss Plan Based on the answers you gave on your consultation, you could lose up to 28 kg! With consistent use, you could get your weight down to 99 kg. UP TO 22% WEIGHT LOSS MOUNJARO 2.5mg(4 Weeks supply) Mounjaro is proven to curb your appetite and help you lose weight, the healthy way! Effective treatment to help you reach your weight loss goals. SAVE £102.00 £229.00 £127.00 UP TO 15% WEIGHT LOSS WEGOVY 0.25mg(4 Weeks supply) Wegovy, otherwise known as Ozempic, is proven to curb your appetite and help you lose weight, the healthy way! Effective treatment to help you reach your weight loss goals. SAVE £102.00 £229.00 £127.00 SELECT A PLAN TO CONTINUE Submit
