National Medical Weight Loss Programme

1) About You

First Name *

Last Name *

Street Address *

Phone Number *

Email Address *

Date of Birth *

Age *

Gender *

Female Male

Weight (st & lbs) *

Height (ft & in) *

BMI (auto-calculated)

Usual blood pressure range? *

2) About Your Health

2.1 Do you suffer from any heart problems? *

Yes No

2.2 Do you have any thyroid problems? *

Yes No

2.3 Thyroid cancer in you or immediate family? *

Yes No

2.4 Pancreatitis (current or past)? *

Yes No

2.5 Kidney problems? *

Yes No

2.6 Liver problems? *

Yes No

2.7 Severe gastro-intestinal problems? *

Yes No

2.8 Diabetes? *

Yes No

2.9 Mental health problems? *

Yes No

2.10 Eating disorder? *

Yes No

2.11 Other medical problems? *

Yes No

2.12 Other medication not already identified? *

Yes No

2.13 Known allergies? *

Yes No

2.14 Permission to inform your GP? *

Yes No

Your GP’s Details

3) About Your Lifestyle

3.1 Do you smoke? *

Yes No

3.2 Do you drink alcohol? *

Yes No

Excessive alcohol can increase health risks. For support cutting down, visit this page.

3.3 Cups of tea/coffee per day? *

3.4 Glasses of water per day? *

NB: Staying hydrated helps reduce constipation.

3.5 Hours of sleep per night? *

NB: Poor sleep affects hunger hormones.

3.6 Exercise/activity per week? *

NB: 150 min moderate or 75 min vigorous recommended.

4) Your Weight-Loss Journey

4.1 Calories per day? *

4.2 Describe your typical daily diet:

4.3 What contributes to your excess weight? *
(tick ALL that apply)

Large portion sizes Emotional eating Compulsive eating Reward eating Waking & eating at night Eating out / takeaways Medication Yo-yo dieting Snacking between meals Lack of exercise Lack of will power Lack of motivation Limited mobility Other

4.4 What weight-loss interventions have you tried?

4.5 Currently taking any treatments (Mysimba, Saxenda, Wegovy, Ozempic, Phentermine)? *

Yes No

5) Declaration & Consent to Treatment

5.1 Tick to confirm each statement: I have answered all questions truthfully and am aware it is a criminal offence to give false or misleading information about my health I am over the age of 18 This prescription request is for my own personal use I will read the patient information leaflet supplied I agree to follow the dosing schedule prescribed I am aware I must combine treatment with a reduced-calorie diet & increased physical activity for best results I agree to record my daily food intake & physical activity I understand there are no guarantees of weight loss If I have not lost 5% of my initial body weight after 12 weeks, I must discontinue treatment I wish to commence the Programme if found suitable and consent to treatment Should I experience any changes in my medical history, I will immediately inform the clinic

5.2 How did you locate this form? *

Website link Facebook link Instagram link Link in an email Link in a message Through a friend Other

Please specify *

Patient Signature *