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Your Health

About You

DO YOU BELIEVE YOU HAVE THE CAPACITY TO MAKE DECISIONS ABOUT YOUR OWN HEALTH; AND THAT YOU DO NOT REQUIRE HELP TO COMPLETE THIS CONSULTATION? *

Yes

WHICH WEIGHT LOSS TREATMENT ARE YOU REQUESTING TODAY? *

Wegovy tablets (daily tablet)

Wegovy injection (weekly injection)

Mounjaro injection (weekly injection)

I want to switch from one weight loss treatment to another

I am not sure which treatment is right for me

WHAT IS YOUR HEIGHT? *

feet/inches

cm *

WHAT IS YOUR CURRENT WEIGHT? *

stones/lb

kg *

Stone *

What is your target weight? *

stones/lb

kg *

Stone *

Your symptoms

Are you currently taking, or have you used in the last 8 weeks, any weight loss medication? *

Your health

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

Yes

Have you engaged in any of the following to manage your weight or body shape: *

Yes

Made yourself throw up for any reason including feeling uncomfortably full
Used diuretics or laxatives to aid weight loss
Believed yourself to be fat when others say you are thin
Intentionally not eating anything for at least 24 hours in an attempt to prevent weight gain

DO YOU HAVE ANY OF THE FOLLOWING? *

Yes

High blood pressure
Abnormal blood fats (dyslipidaemia)
Obstructive sleep apnoea
Cardiovascular disease (for example, heart disease)
Type 2 diabetes

Have you ever had weight loss surgery? *

Yes

Do you have any of the following conditions: *

Yes

Thyroid problems or thyroid cancer in you or a close family member (parent/sibling/child)
Type 1 diabetes
Type 2 diabetes or prediabetes
Diabetic retinopathy, unstable eye disease or recent rapid changes in blood glucose control
Heart failure, or breathlessness at rest or on minimal exertion
Liver disease or ongoing liver problems
Kidney disease or reduced kidney function
Stomach or bowel condition treated with regular medicines (e.g., severe reflux/ulcer, Crohn’s/colitis, IBS)
Gallbladder problems (e.g., gallstones, inflammation)
Pancreas problems (e.g., pancreatitis)
Organ transplant (ever) and taking anti-rejection medicines
Any current cancer diagnosis
Bowel/colon cancer now or in the past

Do you have any allergies? *

Yes

Your Medication

If you are requesting Wegovy tablets, are you taking several medicines first thing in the morning or any medicine where timing or absorption is critical? *

Yes

Not sure

If you are requesting Wegovy injection or Mounjaro injection, are you happy to self-administer by injecting medication just under the skin using a pre-loaded injection pen? *

Yes

If you’re unsure how to inject Mounjaro/Wegovy, please watch the official “How to Use” video and read the step-by-step guides (Mounjaro here) (Wegovy here). These resources cover preparation, injection technique, and safe disposal. If anything’s still unclear, please contact our team before injecting.

If you are requesting Wegovy injection or Mounjaro injection, do you understand that you must use a brand-new needle for each injection? *

Yes

Always use a new needle for each injection. Reusing can increase the risk of infection, and a blunted tip can cause more pain, bleeding, bruising, and skin damage. A fresh needle also helps your pen deliver the full, accurate dose and prevents blockages or contamination of your Wegovy/Mounjaro device.

We’ll include the correct number of needles and a sharps bin for safe disposal with every order.

Do you currently take any of the following medications? *

Yes

Warfarin
Acenocoumarol (Sinthrome)
Insulin
Sulfonylurea medicines for diabetes (for example gliclazide, glimepiride or glibenclamide)
Other oral medications for diabetes
Levothyroxine

Are you taking any other medication, vitamins or supplements? *

Yes

A Bit More About You

Do you have any other medical conditions? *

Yes

Are you pregnant, breastfeeding, planning pregnancy or at risk of pregnancy whilst taking this medication? *

Yes

Pregnancy risk may be defined as late period or unprotected sexual intercourse which may have taken place since your last normal period

Do you currently use oral contraception? *

Yes

Are you using oral HRT? *

Yes

Why are you trying to lose weight? (tick all that apply) *

It’s important to me right now

I’m concerned about my weight

To improve my health

To improve my confidence

To prove a point to myself

My weight is affecting my life

I believe I can lose weight

Other

On a scale of 1–5, how determined are you to lose weight? *

1 (not motivated)

5 (extremely motivated)

What else are you doing to lose weight? (tick all that apply) *

Exercising regularly

Controlling my diet

Behavioural changes (e.g., slowing rate of eating, goals)

Other

Do any of the following apply to you? (tick all that apply) *

I am a smoker

Family history of diabetes

Family history of heart disease

None of the above

Agreement

Do you consent to us sharing consultation information with your GP? *

Yes

Do you understand that you should stop GLP 1 treatment and seek urgent medical advice if you experience: *

Yes

Signs of pancreatitis (severe abdominal pain radiating to the back, persistent vomiting)
Signs of gallbladder problems (right‑sided abdominal pain, fever, jaundice)
Severe dehydration, persistent vomiting/diarrhoea
Vision changes, including sudden or partial vision loss
Symptoms of low blood sugar if you have diabetes
Severe allergic reaction
Severe or worsening mood changes, thoughts of self-harm, or any urgent mental health concern
Any other severe or unusual symptoms

Is there any additional information you’d like to provide, or any questions you have? *

Yes

Do you understand that: *

Yes

For those requesting weight loss injections

Weight loss injections work best with a reduced‑calorie, lower‑fat diet and regular activity; aim for around 150 minutes of moderate exercise weekly.
Doses are weekly, on the same day each week; do not double up.
If you miss 2 or more doses, you must contact us to let us know.
Mounjaro may reduce oral contraceptive exposure during initiation and each dose increase; use condoms/alternative for 4 weeks after each escalation.
This treatment is not suitable in pregnancy or breastfeeding; stop and contact us immediately if you become pregnant.
Report side effects via the MHRA Yellow Card scheme and inform your GP.

For those requesting weight loss tablets

Wegovy tablets work best with a reduced‑calorie diet and regular activity.
You must take one tablet once daily on an empty stomach after a recommended fasting period of at least
8 hours, swallow it whole with up to 120 mL water, and wait at least 30 minutes before food, drink or any other oral medicine.
You must not split, crush or chew the tablet.
You must not take extra tablets or use more than one weight loss treatment at the same time unless our prescriber tells you otherwise.
If you miss a dose, skip the missed dose and take your next dose the following day.
This treatment is not suitable in pregnancy or breastfeeding; stop and contact us immediately if you become pregnant.
Report side effects via the MHRA Yellow Card scheme and inform your GP.

Do you agree that: *

Yes

You will read the Patient Information Leaflet supplied with your medication.
You will contact us and inform your GP if you experience any side effects or start new medicines.
You are over 18 and the treatment is for your own use.
You have answered the questions accurately and truthfully.
You understand the decision about treatment is ultimately the prescriber’s.
You will inform your GP that you have ordered this medication.
The product you order must match the treatment selected in this questionnaire. If it does not match, your order may be delayed, cancelled or require further information before the prescriber can assess it.
By continuing, you agree to our Terms & Conditions, Cancellation Policy and Privacy Policy.

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