Questionnaire weightloss

What is your biological gender?

What are your main reasons for losing weight?
(Choose as many as you want)

General health and lifestyle

What is your height and weight?

Do you have a target weight you want to achieve?

How long have you been struggling with your weight?

What have you tried in the past to lose weight?
(Choose as many as you want)

What challenges have you faced when playing sports or trying to be more active?
(Choose as many as you want)

What challenges have you faced in changing your eating habits?
(Choose as many as you want)

What challenges do you face in maintaining your weight loss?
(Choose as many as you want)

Current medications and health status

Do you suffer from any of the following conditions?

  • Severe hepatic or renal impairment
  • heart failure
  • previous pancreatitis
  • multiple endocrine neoplasia type 2
  • active cancer
  • type 1 diabetes or diabetic retinopathy
  • personal or family history of medullary thyroid cancer
  • a current eating disorder or a history of an eating disorder (e.g., anorexia, bulimia, binge eating disorder)
  • previous gallbladder problems
  • previous inflammatory bowel disease or gastroparesis

Have you been diagnosed with any of these medical conditions?

  • High blood pressure
  • high cholesterol
  • erectile dysfunction
  • sleep apnea
  • asthma
  • osteoarthritis
  • chronic back pain
  • depression
  • PCOS (polycystic ovary syndrome)
  • fatty liver disease
  • chronic malabsorption syndrome

Which of the following conditions do you suffer from?
(Choose as many as you want)

Are you taking any of the following medications?*

  • Insulin
  • Sulfonylureas , e.g. gliclazide
  • Orlistat

Are you taking any other medicines, including GLP-1s, such as Ozempic / Saxenda / Wegovy / Mounjaro ?

Are you taking any of the following medications?

  • Warfarin,
  • Flecainide,
  • Digoxin
  • Methotrexate-Tacrolimus
  • Ciclosporin
  • Rifampicin-Lithium-Phenytoin
  • Carbamazepine
  • Valproic acid

List your current medications, their strength and what you use them for.

Do you suffer from allergies? (e.g. Saxenda , Rybelsus , Ozempic , Trulicity or Victoza)

If you have any other allergies, please let us know here:

When considering treatment options, which of the following are important to you?

Legally effective consent

I understand and confirm that:

  • I am over 18 years old and the medicine is for my personal use only.
  • I will read the full leaflet before taking the medicine.
  • I answered all questions truthfully to the best of my knowledge and belief.
  • Doctors accept my answers and the prescriptions issued are based on my answers. False information can therefore be harmful to your health. I take full responsibility for this.
  • I will inform my doctor about this purchase/prescription at my next visit so that my doctor can continue to monitor my health.
  • I hereby confirm that I have understood the possible side effects of the treatment and have also informed myself about its effectiveness and alternative treatment options.

You are entitled to a telephone call from the pharmacy team to discuss your treatment if you are using it for the first time.

Make your choice:

Can we share information about your treatment with other healthcare professionals?

To help us and other healthcare providers treat you safely, we want to share information about your treatment with us through the LSP (National Switching Point ). This is a secure and accessible platform for other doctors and pharmacists.