Consultation Form

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Age*
You must be over 18 to join the weight loss program
Home
Date of Birth*
DD slash MM slash YYYY
Gender*
Are you pregnant or is there any possibility of you being pregnant?*
Will you be trying to conceive in the next 3 months?*
Are you currently breast feeding?*
What was the date of your last menstrual period?*
DD slash MM slash YYYY
If your last period was more than one month ago, please explain why
Height*
Height*
Weight
Weight
BMI
What is your usual blood pressure range?*

Do you smoke?*
- Yes
- No
How many per day?*
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?*
How many cups of tea or coffee do you drink each day?*
How many glasses of water do you drink each day?*
How many hours of sleep do you average each night?*
How much exercise / activity do you do each week? (NB. This doesn't have to be set time in the gym)*

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*
MM slash DD slash YYYY