About You
Please answer the following questions about yourself (or for the person that will take this medicine) If you get stuck or need any help, use our CHAT button below or give us a Call on 01639 502860
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What is your Body Max Index?
If you're not sure provide and estimate as we can check this before a prescribing decision is made
What is your age (or the person who will use this medication)?
Do you drink alcohol?
If Yes please provide more details on how many units per week and usually when consumed
If you are not the person who will use this medication, please enter their details here (only with their full consent)
Please describe in detail who the intended user is and answer all questions on their behalf
Are you a smoker or an ex-smoker?
If yes please provide more details
What is your biological gender?
Please select your option
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Do you have any medical conditions or previous surgeries?
If yes please provide more details
Do you have cardiovascular (heart) conditions or have had a stroke?
If yes please provide more details
Do you have any liver, kidney or heart problems?
If yes, please provide details
Do you have diabetes?
If yes is this Type I or II?
Is your immune system suppressed through disease, treatment or medication?
If yes please provide more details
Do you take any medicines?
Please list all your current prescription medication, medicines you buy including any herbal medicines and recreational drugs if taken.
Please provide more information about your living and work conditions
e.g. I live with 2 people and a cat, am a painter and decorator
Do you have any allergies?
If yes, please provide details
Do you currently feel severely unwell?
If yes please provide more details
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About your Journey and Health
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What is your ideal weight or size?
You can provide numbers or a vision of what you'd like to achieve
Have you ever tried to lose weight solely by food and exercise?
Please provide more information
Are you currently using any weight management products?
If yes please provide more details
Do you have a history of having an eating disorder?
If yes please provide more details
Do you use levothyroxine (a drug used to treat low thyroid levels)?
If you do, what is your current dose, how long have you taken that dose and when was your latest thyroid blood test?
Do you use the pill as a method of contraception?
If you do, please tell us which medication you take.
Do you have inflammatory bowel disease (ulcerative colitis, crohn's disease etc.)?
Do you currently have, or have a history of pancreatitis?
Has your family a history of Thyroid Cancer type MTC or MEN 2
Have you had a serious reaction to Wegovy before?
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Our Prescribing Contract
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Do you agree with the following?
You will read the patient information leaflet supplied with your medication. The treatment is solely for your use (or the person you have completed this for and with their consent). You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
Can we share this information with your General practitioner?
We advise you to share this treatment with your doctor so they can update your medical records. Please provide their address if appropriate.
Do you agree to tell your doctor or pharmacist about any side effects you may be experiencing with the medicines and any progression of symptoms?
Is there anything else we need to know that is relevant to this consultation?
Do you agree you will contact us and inform your GP if you start new medication or if your medical conditions change during treatment?
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