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Weight Management Consultation Form

Weight Management Consultation Form

Completing this form should take no longer than 5-10 minutes and will assist our clinician in evaluating your suitability for our program. Rest assured that all information provided will be handled with the utmost confidentiality and will only be viewed by our healthcare professionals. During your consultation, you'll have the opportunity to discuss any concerns or questions you may have. Thank you for choosing our clinic to embark on your weight loss journey. We look forward to assisting you!
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Name
Address
Are you registered with a General Practitioner (GP) in the UK?

Medical History

Do you have a history of thyroid disease, including thyroid cancer?
Have you ever been diagnosed with pancreatitis?
Do you have diabetes?
Do you have a history of diabetic retinopathy?
Do you have any eating disorders, or have you had one in the past?
Are you currently dependent on chronic opiates or opiate agonists (e.g. methadone), or are you going through acute withdrawal (cold turkey)?
Do you have a condition that causes seizures, or do you have a history of seizures?
Do you have active coronary artery disease (e.g., ongoing angina, recent heart attack)?
Do you have any allergies?
Do you have liver problems?
Do you have kidney problems?
Have you been told that you have dyslipidaemia, e.g. high cholesterol?
Have you been told that you suffer from sleep apnoea?
Do you have a medical condition or take medication that may contribute to your weight gain?
Have you ever had a serious head injury or head trauma?
Have you been told that you have chronic malabsorption syndrome?
Have you been told that you have cholestasis?
Have you been told that you have inflammatory bowel disease or any severe stomach or gut problem resulting in delayed stomach emptying (called gastroparesis)?
Do you have any problems with your pancreas?
Do you have a current or past history of depression?
What is your current level of physical activity?
Smoking Status
Alcohol consumption
Have you tried any weight loss programs or diets in the past?
Have you experienced any side effects from previous weight loss medications?
Are you currently pregnant or planning to become pregnant?

Consent

Do you agree to allow our clinician to access your GP records via the National Care Records Service (NCRS)?
I hereby confirm that the information provided is accurate to the best of my knowledge and I understand that this information is crucial for safe and effective weight loss treatment.