Weight Management ConsultationStep 1 of 425%This consultation takes about 3 minutes. A UK-registered prescriber will review your answers and a telephone consultation may be needed before any treatment is supplied. Treatment is not guaranteed.First name(Required)Surname(Required)Email(Required) Phone number(Required)Contact consent(Required) I consent to Bury Healthcare Online contacting me about this consultation.Date of birth(Required) DD slash MM slash YYYY Are you a UK resident?(Required) Yes NoGender at birth(Required) Female MaleAre you pregnant, planning pregnancy, or is there any possibility you could be pregnant?(Required) Yes NoAre you breastfeeding? Yes NoHeight in cm(Required)Weight in kg(Required)BMI (calculated)Do any of these apply to you? (select all that apply)(Required) Personal or family history of medullary thyroid cancer Multiple Endocrine Neoplasia type 2 (MEN2) Known allergy to semaglutide or GLP-1 medicines Type 1 diabetes History of pancreatitis Current or past eating disorder None of these apply to meBased on your answers, treatment may not be suitable for you. You can still submit — a prescriber will review and contact you.Verification — so our clinician can confirm your details before any treatment is dispensed.Weight verification photo(Required)Accepted file types: jpg, jpeg, png, heic, pdf, Max. file size: 4 GB.Upload a recent, clear, full-length standing photo of yourself. Our clinician uses this to confirm your starting point.Photo ID(Required)Accepted file types: jpg, jpeg, png, heic, pdf, Max. file size: 4 GB.Upload a photo of your passport or driving licence to confirm your identity and age.Have you tried to manage your weight through diet and exercise?(Required) Yes NoDo you have any liver, kidney or heart problems?(Required) Yes NoPlease provide detailsDo you have a history of any mental health conditions (including anxiety, depression or an eating disorder)?(Required) Yes NoPlease provide detailsPlease list all your current medication, including anything you buy over the counter.Do you have any allergies?(Required) Yes NoPlease provide allergy detailsAre you currently using, or have you previously used, any weight-loss treatment?(Required) Yes NoWhich treatment, what strength, and for how long?What is your blood pressure?(Required) Normal High I do not knowWhat is your target weight?Is there anything else you would like the prescriber to know? (Include any preference, though your prescriber decides what is clinically suitable.)May we notify your GP about this consultation? (recommended)(Required) Yes NoPlease provide your GP name and addressHow did you hear about us? Search engine Social media Friend or family OtherDo any of these apply to you? (select all that apply)(Required) Gallbladder disease or gallstones Diabetic retinopathy Thyroid disease or thyroid nodules Type 2 diabetes Severe stomach or gut problems / gastroparesis None of theseDo you take any medicine for diabetes (e.g. insulin, sulfonylurea, metformin)?(Required) Yes NoAre you currently using any other GLP-1 or weight-loss medicine?(Required) Yes NoDo you have any of these weight-related conditions? (select all that apply) High blood pressure Raised cholesterol Prediabetes or type 2 diabetes Sleep apnoea Heart disease None of theseDo you smoke?(Required) Yes NoHow much alcohol do you drink?(Required) None Occasionally RegularlyDo you take levothyroxine, or any other medicine where the dose must be precise?(Required) Yes NoIf an oral tablet is prescribed, your clinician will advise on timing and may check your thyroid levels.The oral tablet must be taken on an empty stomach after an 8-hour fast, with only a sip of water, then nothing for 30 minutes. Are you able to follow this?(Required) Yes No Not surePlease read and confirm:Do you consent to a GPhC-registered prescriber accessing your NHS Summary Care Record (SCR) to confirm your medical history and current medication?(Required) Yes, I consent No, I do not consentThis helps us prescribe safely. You can still proceed if you decline — your prescriber will verify your history another way.Clinical consent(Required) I confirm the information I have given is accurate and complete to the best of my knowledge. I understand a UK-registered prescriber will review my consultation, may need to verify my identity and BMI (including by video where required), and that treatment is supplied only if the prescriber judges it clinically suitable — it is not guaranteed. I consent to a GPhC-registered prescriber reviewing my information and, with my consent, contacting my GP. I have read and understood how my data will be used. [Draft — pharmacist to approve.]
