Name*

First Last

Phone*

Email*

What is your height? (cm)*

What is your weight? (kg)*

Do you have a goal weight you would like to achieve? If so, please write it below.

What is your biological sex?

Male

Female

Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before?*

Yes

No

Have you ever suffered with an eating disorder?*

Yes

No

Are you pregnant, breastfeeding, or trying to conceive?*

Yes

No

Have you been diagnosed with or had surgery for any of the following?

Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?*

Yes

No

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?*

Yes

No

Are you taking steroids or medication to treat your thyroid?*

Yes

No

Have you taken injectable weight loss medication in the last 4 weeks?*

Yes

No

Are you currently in the sixth month of continuous treatment with injectable weight loss medication?*

Yes

No

Name of your GP*

First Last

Email of your GP*

Name of your GP practice*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

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