Medical Assessment

Questionnaire

Eligibility

Safety

Review

Had a prescription in the last 12 months?
Save time by reusing your pre-filled questionnaire.

Complete our questionnaire to:

Start or continue your treatment
Adjust your dose
Switch medication

Are you using weight loss medication?

Yes No

Please enter your height (cm)

We need this to calculate your BMI accurately.

Please enter your weight (kg)

Do not guess your weight.

Questions to help determine whether you are eligible for this treatment:

1 - How would you describe your ethnic background?

What’s considered a healthy weight can be different depending on your ethnic background. Tell us how you describe yourself so we can ensure you’re getting the right care.

I'd prefer not to say

Asian or Asian British

Includes mixed Asian, Pakistani, Bangladeshi, Chinese & other Asian backgrounds

Black, Black British, Caribbean, African

Includes mixed Black and other Black backgrounds

Middle Eastern

White

Includes English, Welsh, Scottish, Northern Irish, Irish, Roma or other White backgrounds

None of the above

Do you have any of these conditions?

Diabetes High blood pressure None

Have you ever had an eating disorder?

Yes No

Do you have kidney disease?

Yes No

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

Yes No

Your Postcode

I confirm all information is accurate and I understand the risks.

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