Weight Loss Consultation Step 1 of 15 6% URLThis field is for validation purposes and should be left unchanged.Your detailsEmail(Required) Name(Required) First Last Question 1(Required)How old are you? Under 18 18 to 74 75 to 85 Over 85 Question 2(Required)Are you male or female? Male Female Question 3(Required)Your Height Metric Imperial Question 3b(Required)Question 3c(Required)Question 3d(Required) Question 4(Required)Your Weight Metric Imperial Question 4b(Required)Question 4c(Required)Question 4d(Required) Question 5(Required)Your ethnicity Asian or Asian British Black or Black British Mixed or multiple ethic group White Other ethnic group Not Listed Question 5b(Required)! Please specify Question 6(Required)How much time do you spend exercising per week? None Less than 1 hour Between 1 and 5 hours More than 5 hours It is recommended that patients prescribed weight loss treatment incorporate a comprehensive approach to manage their health, which includes maintaining a balanced diet, engaging in regular physical activity, and adopting a healthy lifestyle. To optimise the therapeutic benefits of weight loss treatment, we advise patients to undertake at least 150 minutes of moderate-intensity exercise per week. Question 7(Required)What do you think about your diet? Here are some options: Mainly fast food and processed items A mix of good and not-so-good food choices Mostly healthy, filled with fruits, veggies, and whole grains Unsure or don't really focus on what I eat Acknowledging dietary challenges is crucial for your health improvement. To complement your treatment with medications, adopting a balanced diet and reducing calorie intake are essential steps. We suggest starting with manageable changes: increase fruits and vegetables, opt for whole grains, include lean proteins, and importantly, reduce processed foods and sugary snacks. Cutting down on portion sizes and avoiding high-calorie meals can significantly contribute to your overall calorie reduction. Our team is prepared to offer further guidance and connect you with a health professional for personalised advice. Question 8(Required)Have you ever been diagnosed with any of the following? Liver disease Pancreatitis Diabetes type 1 Diabetes type 2 Diabetic retinopathy/diabetic eye disease Heart Failure Kidney Problems Thyroid cancer or family history of thyroid cancer Gallstones Weight related surgery Fast heart rate (Tachycardia) Multiple endocrine neoplasia 2 (MEN2) Suicidal thoughts Eating disorders Cholestasis Chronic malabsorption syndrome Yes No Question 8b(Required)Please provide further details Question 9(Required)Do you have any of the following weight-related conditions? Hypertension (high blood pressure) Dyslipidaemia (high cholesterol) Cardiovascular disease Pre-diabetes Knee or hiposteoarthritis Obstructive sleep apnoea Asthma/chronic obstructive pulmonary disease (COPD) Liver disease (non-alcoholic fatty liver disease (NAFLD) or non-alcoholic steatohepatitis (NASH) and polycystic ovary syndrome (PCOS) Erectile dysfunction Yes No Question 9b(Required)Please provide further details Question 10(Required)Have you previously or are you currently using any other weight loss treatment? Ozempic (semaglutide) Saxenda (liraglutide) Rybelsus (semaglutide) Mysimba (naltrexone/bupropion) Orlistat (alli) Victoza (liraglutide) Mounjaro (tirzepatide) Trulicity (dulaglutide) Wegovy (semaglutide) Other Never taken weight loss treatment Question 10b(Required)Could you please share with us when you first started taking this medication, how long you've been using it, and the last time you took it? It helps us understand your treatment history better. Please specify: Question 11(Required)Do you have any allergies? Yes No Question 11b(Required)Please provide further details. Question 12(Required)Are you taking any other medication (on prescription or over the counter)? Yes No Question 12b(Required)Please provide further details. Question 13(Required)I understand that the medication has specific storage and usage requirements and I will check this information in the leaflet provided. I Understand Question 14(Required)You can find a copy of our terms and conditions here. I Consent