Weight Loss Doctors | The Weight Loss Doctor | Slimming Tablets Cardiff | Slimming clinic | Slimming tablets Swansea

Consultation Form

Please provide NHS Number (If you know it)

Full Name *

Date of Birth *

Contact Number *

Contact Email *

Address *

Postcode *

Are you happy for us to leave a text or voice mail? *

Yes

Your weight *

Your Height *

Any recent weight loss medication

Any Prescribed or over the counter medication you are taking

What are your primary reasons for wanting to lose weight? (Please select all that apply)

I am worried about obesity

My weight affects my personal life

My weight affects my health

Feeling sad or depressed

Lack of energy or motivation

Diet and exercise haven’t resulted in any weight loss

Need to lose weight for an event (social event, surgery)

Other (please explain)

It is important to maintain a healthy lifestyle while using weight loss medications. Weight loss medications are not intended to replace a balanced diet and regular exercise. *

OK, I understand

Do you have any of the following thyroid conditions? (Please select all that apply)

Overactive thyroid (Hyperthyroidism)

Underactive thyroid (Hypothyroidism)

Thyroid cancer (you or your close family)

Multiple endocrine neoplasia syndrome type 2/MEN 2 (you or your close family)

Other thyroid disease

None of the above

Do you currently have or have you ever had any of the following gut problems? (Please select all that apply)

Crohn's disease or ulcerative colitis

Pancreatitis

Diabetic gastroparesis

None of the above

Do you have problems with your gallbladder?

Yes, I get gallbladder inflammation or gallstones

No, because I had my gallbladder removed

Are you currently or have you previously been diagnosed with an eating disorder? Please note, we do not consider overeating to be an eating disorder. * Binge eating disorder is a condition where people eat large amounts of food in a short period of time and experience a loss of control of what or how much they are eating.

Anorexia nervosa

Bulimia

Binge eating disorder

None of the above

If you think you may have an eating disorder please speak to your doctor who can assess you further. We understand that not everyone with an eating disorder has been diagnosed. It is important to note that: >Appetite suppressants can trigger those with bulimia or anorexia. >Binge eating may lead to results being different than expected

Ok, I confirm I don't have a eating disorder

Do you have any other medical conditions that we haven't asked about yet? *

Yes

Do any of the following apply to you? (Please select all that apply)

Pregnant

Trying to get pregnant within the next 2 months

Unsure if pregnant

Breastfeeding

None of the above

Are you using any of these medications? (Please select all that apply)

Metformin

Digoxin

Lithium

Oral contraceptive pills

Any treatment for diabetes Such as insulin or any other injections, gliclazide, dapagliflozin

Warfarin

None of the above

Do you use any other medication? * This includes anything that you are prescribed or have bought over the counter, or online, such as creams/ointments, vitamins or supplements, eye drops, gels, inhalers or the contraceptive pill.

Yes

Do you have any allergies? * Please note that this includes any dietary allergies e.g. lactose or gluten.

Yes

Patient Agreement * We require your informed consent before we are able to complete your treatment request. Please read the following statements carefully. >I agree to read the patient leaflet before taking any medication prescribed to me. >I fully understand the questions in this questionnaire and have answered honestly and truthfully. >I fully understand the side effects of the treatment options, their effectiveness and alternative options, and am happy to continue with this request. >I confirm and agree that any treatment prescribed to me is for personal use only. >I understand that decisions about treatment are for both the prescriber and the patient to jointly consider during the consultation process, but the final decision is that of the prescriber. Upload ID: We need to confirm your identity, your data will be held on our secure clinical system and only be used to verify your identity when prescribing the medication. Upload a photo of yourself: We need to confirm your body size, this is to protect patients who might have eating disorders and try to purchase medication online. A photo of you standing where we can see your body habitus will allow us to determine if the weight you have stated is likely. By clicking 'Continue' you signify that you have read, understand and agree to abide by our terms and conditions and privacy policy.

Continue

Which Pricing tier would you like? * If you select the face to face options after submitting the form you will be taken to the booking page where you can book you face to face appointment. Please select new patient and the clinic you would like. Please note the deposit taken will be taken off the cost of your treatment if you go ahead.