Health Questionnaire

    If you are looking for a weight management solution, please complete the following questionnaire to help us better understand your health. It’s very similar to visiting a GP but from the comfort of your own home. Our independent pharmacist prescriber will review your responses and confirm approval of your treatment. If we can’t prescribe you a treatment, no payment is taken and we’ll do our best to suggest alternative options.

    Please tell us your height?

    What is your current weight?

    Do you smoke?

    Do you drink alcohol on a regular basis?

    Do you suffer from any intolerances or allergies?

    Do you suffer from any heart conditions? (e.g. high or low blood pressure, previous heart attacks, angina, irregular heart rhythm)

    What is your blood pressure?

    Do you suffer from any breathing problems or respiratory conditions? (e.g. asthma, COPD, bronchiectasis)

    Do you have any kidney problems?

    Do you have any liver problems? e.g. hepatitis, fatty liver, alcohol liver disease

    Do you suffer from any form of sugar or insulin conditions? (e.g. diabetes, thyroid problems)

    Do you suffer from any mental health conditions? (e.g. anxiety, depression, personality disorder)

    Do you or have you suffered from any neurological problems? (e.g. parkinsons, previous stroke or mini-stroke)

    Please tell us about any operations you have had or are scheduled to have.

    Do you suffer from any other medical conditions?

    Is there a history of any medical disorder that runs in your family?

    What is your Gender?

    Are you, or could you be pregnant?

    Are you trying to become pregnant?

    Are you breastfeeding?

    Have you previously or are you currently taking any weight loss treatments? (e.g. Xenical, Alli or Phentermine)

    Have you purchased any other weight loss medications either in stores or on the internet?

    How else have you tried to lose weight? (e.g. Consulted your GP, exercise or diet)

    Are you currently withdrawing from alcohol or benzodiazepines? (e.g. diazepam)

    Are you taking or have you taken any prescription painkillers in the last 3 months?

    How many calories do you think you consume on the average day?

    Do you regularly eat take away or highly processed food? (e.g. Pizza, burgers, fried chicken)

    Do you regularly eat crisps/chocolates/cakes?

    How many hours of exercise do you do each week?

    Do you or have you ever suffered from an eating disorder? (such as Anorexia Nervosa or Bulimia)

    Have you been diagnosed with any of the following conditions?

    High blood pressure?

    Please select date when you were diagnosed

    Type 2 diabetes?

    Please select date when you were diagnosed

    Dyslipidemia? (such as high cholesterol or high triglycerides in the blood)

    Please select date when you were diagnosed

    Please tell us anything else that may be important to this consultation

    Thank you for filling in the questionnaire. Before we proceed to the checkout, please provide a few personal details and state what you would like to order:

    Please note that we will not take any payment from you until your questionnaire has been reviewed by our experts. Please watch out for one of two responses - an approval e-mail or a rejection. If we have to reject your order for any reason, we be in touch to discuss alternative options.

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