Medical weight management - pre appointment

Name*

Do you suffer from any heart problems?*

Yes

No

Do you suffer from any thyroid problems? (Grave's disease, hypothyroid, hyperthyroid)*

Yes

No

Have you or any immediate family member ever been diagnosed with thyroid cancer?*

Yes

No

Have you ever had pancreatitis? *

Yes

No

Have you ever had any liver probelms? *

Yes

No

Have you ever had any eye probelms? *

Yes

No

Have you ever had any gastrointestinal probelms? *

Yes

No

Do you have diabetes?*

Yes

No

Have you ever had any mental health problems?*

Yes

No

Have you ever been diagnosed with an eating disorder?*

Yes

No

Do you have any known allergies?*

Yes

No

If you answered yes to any of the above questions you can give more information in this box.

Are you currently taking any weight loss medications? (wegovy, ozepmic, mounjaro, saxenda)*

Yes

No

Please list your current medications. (Please include supplements and herbal medicines)*

It is our policy to inform your GP of any changes to your medications - if you consent to this please let us know your GP's address below.

Do you smoke?

Yes

No

Describe your typical daily diet.

Describe your typical weekly exercise and activity.

What do you think contributes to previous problems with your weight management? (eg large portion sizes, poor mobility, lack of motivation)

What weight management strategies have your tried before? (eg diets, weight watchers, GP advice, personal training)

How motivated are you to lose weight at this time (1 = not motivated at all, 5 = extremely motivated)

How motivated are you to change your eating and exercise habits? (1 = not motivated at all, 5 = extremely motivated)

How satisfied would you be with 15% weight loss in 6 months time? (1 = not at all satisfied, 5 = extremely satisfied)

I confirm that I have answered all questions truthfully - I understand that providing misleading or false information about my health can be a criminal offence. I confirm that if my medical circumstances change I will inform my doctor. I confirm that this treatment is for my use only. I understand that it is at my doctor's discretion to start medical treatment and that this can be stopped at any time if medically indicated. I understand that the information I provided in this submission will be held securely in my medical record at The Stockbridge Clinic. *

Yes

No

Weight Management

PRE APPOINTMENT consultation