Weight Loss

Have you ever previously attempted to lose weight by both diet and exercise?

Do you currently or have you previously used any medication to help you lose weight?

Do you currently suffer with any of the following conditions?
- Thryoid cancer or other thyroid issues

- Issues with absorbing food (such as chronic malabsorption)

- Cancer treatment / End stage renal disease / Significant liver dysfunction

- Severe heart failure / Diagnosis of pancreatitis
- Cholestasis

How much exercise do you undertake on an average week?

Do any of the following statements describe your condition?
These conditions are frequently weight-related and may be improved by weight loss.

I have been diagnosed with hypertension (high blood pressure).
I have a heart/cardiovascular condition.
I have elevated cholesterol.
I have pre-diabetes.
I've got osteoarthritis.
I have sleep apnoea.
I suffer from erectile dysfunction.
I suffer from asthma or COPD.
I suffer from fatty liver disease.
I suffer from polycystic ovary syndrome (PCOS)

Have you ever previously been diagnosed or suffer with an eating disorder such as anorexia or bulimia?

Do you or have you ever previously suffered with any kidney or liver impairment or damage?

Have you ever previously been diagnosed with Atrial Fibrillation or any condition related to heart beat rhythm?

Have you ever previously been diagnosed with heart failure?

Do you or anybody in your family have any history of thyroid cancer, any previous thyroid issues or any endocrine issues?

Have you ever been diagnosed with any other medical conditions?

Do you suffer with any allergies?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Are you currently pregnant, planning a pregnancy or breastfeeding?

Is there any other information you would like to share with our prescribing team?
You are already with another provider? (Submit evidence)
You suffer with any type of other medical issue not mentioned in the form already?

This will enable the clinician to better understand your situation and if this medication will be suitable for you.

We strongly recommend that you inform your GP of any treatment you receive. Would you like us to do this on your behalf?

Do you agree to the following?
- I am between the ages of 18 and 65
- This treatment is for my use only
- I have the capacity to make decisions about my own healthcare
- I have understood all the questions and have answered this consultation truthfully and completely
- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health
- I will read the patient information leaflet supplied with this medication
- I will contact Rutland Pharmacy and inform my GP if I experience any side effects from this treatment or if there are any changes to my health
- I have read, understood and agree with our Terms and Conditions

Please confirm your mobile number and best time to contact you directly.

You may be contacted by our prescribing clinician within the next 72 hours to confirm details or request further information.

This call may come from a unknown number.