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Consultation Form
Step 1 of 5 - About You
20%
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone
*
Email
*
Age
*
You must be over 18 to join the weight loss program
Home
Date of Birth
*
Date Format: DD slash MM slash YYYY
Gender
*
Male
Female
Transgender
Are you pregnant or is there any possibility of you being pregnant?
*
Yes
No
Will you be trying to conceive in the next 3 months?
*
Yes
No
Are you currently breast feeding?
*
Yes
No
What was the date of your last menstrual period?
*
Date Format: DD slash MM slash YYYY
If your last period was more than one month ago, please explain why
Height
*
4ft
5ft
6ft
7ft
Height
*
0in
1in
2in
3in
4in
5in
6in
7in
8in
9in
10in
11in
Weight
5st
6st
7st
8st
9st
10st
11st
12st
13st
14st
15st
16st
17st
18st
19st
20st
21st
22st
23st
24st
25st
26st
27st
28st
29st
30st
31st
32st
33st
34st
35st
36st
37st
38st
39st
40st
Weight
0lbs
1lbs
2lbs
3lbs
4lbs
5lbs
6lbs
7lbs
8lbs
9lbs
10lbs
11lbs
12lbs
13lbs
BMI
What is your usual blood pressure range?
*
Low - 90/60 or Below
Normal - Between 90/60 and 139/89
High - 140/90 or Above
Do you suffer from any heart problems?
*
Yes
No
Please give details
*
Do you have any thyroid problems?
*
Yes
No
Please give details
*
Have you, or anyone in your family ever had thyroid cancer?
*
Yes
No
Please give details
*
Do you currently, or have you ever had pancreatitis?
*
Yes
No
Please give details
*
Do you suffer from any kidney problems?
*
Yes
No
Please give details
*
Do you suffer from any liver problems? e.g. hepatitis, fatty liver, alcohol liver disease
*
Yes
No
Please give details
*
Do you suffer from inflammatory bowel disease?
*
Yes
No
Please give details
*
Do you suffer with diabetes?
*
Yes
No
Are you taking Insulin?
*
Yes
No
Please give details
*
Do you suffer from any mental health problems? e.g. anxiety, depression, personality disorders
*
Yes
No
Please give details
*
Do you suffer with an eating disorder?
*
Yes
No
Please give details
*
Do you have any other medical problems?
*
Yes
No
Please give details
*
Are you taking any other medication not already listed above? (Prescribed or bought over-the-counter)
*
Yes
No
Please list all medicines and what they treat.
*
Do you have any known allergies?
*
Yes
No
Please list your allergies.
*
It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'YES' below to give us your permission to do so.
*
Yes
No
Please provide full contact details for your GP
*
Do you smoke?
*
Yes
No
How many per day?
*
1-5
6-10
10-15
15-20
20-30
30-40
40-50
50+
Do you drink alcohol? Please copy and paste this link to calculate your units https://www.drinkaware.co.uk/sevendaycalculator
*
Yes
No
How many units per week?
*
1-5
6-10
10-15
15-20
20-30
30+
How many cups of tea or coffee do you drink each day?
*
None
1-2
3-4
5-6
7-8
9+
How many glasses of water do you drink each day?
*
None
1-2
3-4
5-6
7-8
9+
How many hours of sleep do you average each night?
*
Less than 4
5-6
7-8
8+
How much exercise / activity do you do each week? (NB. This doesn't have to be set time in the gym)
*
Very Little
One Hour
Two to Three Hours
More than Three Hours
How many calories do you consume per day?
*
Less than 1000
1000-1500
1500-2000
2000-2500
More than 2500
Do you eat three meals a day?
*
Yes
No
Please describe your typically daily diet
*
Do you crave certain foods?
*
Yes
No
Please provide details
*
Do you regularly eat take away food (eg Pizza, burgers, fried chicken)?
*
Yes
No
Please provide details
*
Do you regularly eat crisps / chocolates / cakes?
*
Yes
No
Please provide details
*
Have you previously or are you currently taking any other weight loss treatments such as Xenical, Alli or Phentermine?
*
Yes
No
Please describe which one and when did you last take this treatment? How long did you take the treatment for?
*
Please tell us which diets you have tried before
*
I confirm that I have answered all the above questions truthfully
*
Yes
Should I experience any changes in my medical history, I will immediately inform the clinic
*
Yes
I understand that the Pen MUST be used in conjunction with a reduced calorie diet, and increased physical activity for best results.
*
Yes
I agree to record my daily food intake and physical activity
*
Yes
I agree to follow the guidelines provided
*
Yes
I confirm that no guarantees for weight loss have been given, and that results will vary from individual to individual. I am also aware that around 1 - 2% of people do not respond to saxenda, but the reason for this is unknown, and I accept this possibility
*
Yes
I agree to read the patient leaflet before starting the Pen
*
Yes
I wish to commence the program if I am found to be a suitable candidate following my consultation, and I consent to treatment
*
Yes
Please type your full name to sign this document
*
Date
*
Date Format: MM slash DD slash YYYY