Weight-loss form – The Kingston Pharmacy

Welcome to our Weight-loss programme

Please fill out this form so your clinician can recommend the best treatment plan for you.

Have you completed this form before?

New patient

Returning patient

Do you have a treatment preference?

Wegovy

Mounjaro

Sexenda

Other

No preference

What 'other' treatment do you prefer?

First Name

Last Name

Phone/Mobile

Address

Address Line 1

City

Postcode

Country

Date of birth

Sex at birth

Male

Female

What is your height?

Imperial (feet and inches)

Metric (metres and cm)

meters

Inch

What is your current weight?

Imperial (stone and pound)

Metric (kg)

lbs

Do you have any of the following conditions?

Diabetes

Pre-diabetes

High blood pressure

High Cholesterol

Chronic Malabsorption

Heart Failure

Pancreatitis

Other

No health conditions

What 'other' health conditions do you have?

Are you currently pregnant, breastfeeding, or trying to get pregnant?

Pregnant

Trying to get pregnant

Breastfeeding

None of the above

Do you / have you ever smoked?

Cigarettes

Vape

Rolled cigars

Never smoked

Quit smoking

Do you drink alcohol?

Yes

How many units of alcohol do you drink a week?

Up to 14 units

Over 14 units

Have you had any recent surgical/medical procedures, including surgery for the purpose of weight loss?

Yes

Please describe the procedure and when you had it

Do you suffer from any mental health problems?

Yes

Please provide more details

Are you currently withdrawing from alcohol or benzodiazepines?

Yes

Please provide more details

Are you currently taking any medication? including non-prescription medicines, or have you recently finished a course of medication?

Yes

Please give more details about the names of the medicines and what you take them for

Are you allergic to any medicines or other substances?

Yes

what you are allergic to and the nature of the allergy?

Have you noticed any changes in your weight since starting the injections?

Yes

Please provide more details

Have you experienced any side effects since starting the weight loss injection?

Yes

Please provide more details on the side effects

What is your main reason for seeking medication to help you lose weight

What is your target weight?

What is your desired time frame for achieving this weight loss goal

Have you previously used, or are you currently using, any weight-loss treatments; including prescription and non-prescription treatments?

Yes

When did you last use the weight-loss medication?

Less than 4 weeks ago

More than 4 weeks ago

Have you experienced any side effects from previous weight-loss medications?

Yes

Please details the name of the medication and side effects experienced

Are you following any specific diet in conjunction with the injections?

Yes

Please provide more details on the diet you are following

Are you following any specific workout routine in conjunction with the injections?

Yes

Please provide more details on the workout routine you are following

What is your current estimated daily calorie intake?

Do you consider your current diet to be healthy?

Strongly disagree

disagree

Neither agree or disagree

Agree

Strongly agree

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

Yes

How many doses do you currently have remaining?

When do you anticipate needing the next supply?

Preferred method of receiving the re-supply

Pick up

Delivery

Delivery Address

Address Line 1

City

Postcode

Country

Is you preference to stay on the same dose or increase your current dose?

Stay on the same dose

Increase the dose

Do you have any concerns that you would like the clinician to follow up on with you

Yes

Select follow-up Appointment Date & Time

Are you currently registered with a UK GP practice

Yes

I don’t know

Would you like us to inform your GP that you are now on this medication so that in the future they take medicine interactions into account when prescribing anything new

Yes, inform my GP

No, I will take responsibility for checking interactions with my healthcare provider

Please provide details of your GP

I consent to have this website process my submitted information so they can respond to my inquiry

Welcome to our Weight-loss programme

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