Step 1/6: Begin Free Consultation Leave this field blank Answer these questions to get the most effective clinically proven treatments for you. First Name Surname Date of Birth Email Phone number Gender at Birth Male Female Are you breast feeding? Yes No Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? Yes No Do you drink alcohol or smoke? Yes No Please provide details eg: How many cigarettes do you smoke per day and/or how many units of alcohol do you consume per day. Have you received advice from a weight management counsellor before? Yes No Have you tried to manage your weight by altering your diet and increasing physical activity? Yes No Do you have a medical history of any of the following listed below? Select multiple if needed Diabetic gastroparesis Diabetes Inflammatory bowel disease Ketoacidosis Congestive heart failure Severe renal impairment Thyroid disease Pancreatitis Gall Stones Dysglycaemia Hypertension Dyslipidaemia Obstructive sleep apnoea None of these Please choose the statement that best fits you. Body weight can impact your mental health, pick one statement that best fits you. I have been diagnosed with a mental health condition such as depression and/or anxiety. I have been diagnosed with eating disorders such as anorexia, bulimia and/or body dysmorphia. I have never been diagnosed with any mental health conditions or eating disorders. How often do you regularly exercise? I do not exercise I exercise 1-2 hours a week I exercise 3 plus hours a week Has a low-calorie diet failed to manage your weight in the past? Yes No Would you object to a low-calorie diet as part of treatment? Yes No Do you have any liver, kidney or heart problems? Yes No Please provide some details Do you know your Body Max Index? Yes No Please list it below. Height State your height in Feet & inches or Cm. PLEASE PICK ONE Feet & Inches Cm Feet & Inches Please state your height in feet and inches Feet & In Cm Please state your height in cm Cm Weight State your weight in Stones & lb or Kg. PLEASE PICK ONE Stones & lb Kg Stones & lb Please state you weight in Stones & Pounds Stones & lb Kg Please state your weight in Kg Kg What is your target weight? What weight would you like to be? What is your blood pressure? Normal (between 90/60mmHg and 120/80mmHg) High (140/90mmHg or higher) Low (90/60mmHg or lower) Unsure Do you have any allergies? Yes No Please provide details Are you currently using any weight loss products? I have tried Saxenda injections before I have tried Ozempic injections before I have tried Xenical (Orlistat/Alli) capsules before None of these Other Please provide details Do you have any recent or past medical history of note? e.g. other medical conditions that you have previously been treated for. Yes No Please provide details Do you have a history of any mental illnesses, including anxiety or depression? Yes No Please provide details Please list all your current prescription medication including any medication you buy over the counter. If you do not have any just leave blank Are you aware that Ozempic is being prescribed 'off-label' for weight loss and what this means? 'Off-Label' use of a medicines involves the use of a medicine that has a marketing authorisation but for an indication (condition), at a dose, via a route or for a patient category (e.g. age) that is not listed in the Summary of Product Characteristics for that medicine (off-label use). If you have any questions please contact us where we'll be happy to discuss further Yes No Is there any particular treatment you prefer? Mounjaro Wegovy Xenical/Orlistat Rybelsus (Off-Label) Other Please provide details Do you agree to inform us, your GP or seek appropriate medical attention if you suffer from any persistent hoarseness, sore throat, difficulty swallowing or any lumps in your neck? Yes No What is your waist circumference? (Measure your waist circumference just above your belly button, breathe out gently and take your measurement. You can repeat this a few times just to be sure) How did you hear about us? Other Yahoo Bing Another Website Google Word of Mouth Please provide details Please provide details DO YOU AGREE AND CONSENT TO THE FOLLOWING? • I am over the age of 18 years and live in the UK. • I will familiarise myself with the patient information leaflet included with the medication. • I will report any side effects and changes in my health to Bury Healthcare Online and/or your GP. • I will contact Bury Healthcare Online and inform my GP if I experience side effects to any treatment, if my medical history changes, if I start any new medications or if I experience any symptoms or my medical conditions change in any way. • I shall be the sole user of any medication offered to me through this service. • I confirm all answers are provided by me, and will be truthful. I agree to the terms and conditions Next
