Medical Assesment

Name

First

Last

Email

Mobile No.

What is your height and weight?

Imperial
Metric

Do you suffer from prediabetes, diabetes, heart disease, high blood pressure, high cholesterol or obstructive sleep apnoea?

Yes
No

Are you between the ages of 18 and 74?

Yes
No

If you have type 2 diabetes, are you on any injections or tablets to control your blood sugar, other than metformin?

Yes
No

Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before?

Yes
No

Have you ever suffered with an eating disorder?

Yes
No

Are you pregnant, breastfeeding, or trying to conceive?

Yes
No

reduce injectable Semaglutide,

Have you been diagnosed with or had surgery for any of the following?
Acromegaly or any growth hormone problem
Chronic Malabsorption Syndrome Cushings Syndrome

Have you been diagnosed with or had surgery for any of the following?

Yes
No

Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?

Yes
No

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

Yes
No

Are you taking steroids or medication to treat your thyroid?

Yes
No

Have you taken injectable weight loss medication in the last 4 weeks?

Yes
No

Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you:

Yes
No

Do you agree to the following?
You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Do you agree to the following?

Yes
No

Do you understand that GLP-1 injectable weight-loss medication (such as Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment?

Yes
No

Do you understand that this 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?

Yes
No

Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?

Yes
No

Do you understand that injectable weight loss medications should not be used with other weight loss medications?

Yes
No

Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?

Yes
No

Both weight loss and injectable weight loss treatment has been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental health issues), do you understand you should stop treatment and speak to your doctor?

Yes
No

final aggrement

I agree to the Terms and Conditions and I confirm that I am over 18
I agree to my prescription being issued faster via the assisted prescribing service, if eligible.

Height

Weight

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