Your Name *
Your Email *
Please provide your height *
Feet —Please choose an option—03 ft04 ft05 ft06 ft07 ft08 ft
Inches —Please choose an option—00 in01 in02 in03 in04 in05 in06 in07 in08 in09 in10 in11 in
Please provide your current weight (kg) * —Please choose an option—404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200
Are you male or female? * —Please choose an option—MaleFemale
What is your target weight for the next 12 months? * —Please choose an option—404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200I have no target weight in mind
Have you previously taken any medicine(s) to help with weight loss? *
Yes
No
How many calories do you think you consume daily? * —Please choose an option—Less than 15001500 - 20002000 - 30003000 - 4000More than 4000I know the exact amountI don't count calories
How many times a week do you exercise for more than 20 minutes? *
Exercise is any activity that increases your heart rate, including an active job or a brisk walk.
—Please choose an option—Little or no exercise1 to 2 times3 to 4 times5 to 6 times7 times +
Do you drink alcohol? * —Please choose an option—NoYes - 1-2 units/weekYes - 3-5 units/weekYes - 6 or more units/week
Have you been diagnosed with high blood pressure (with or without treatment)? *
Have you been diagnosed with Diabetes (with or without treatment)? *
Have you been diagnosed with an underactive thyroid, for which you take Levothyroxine? *
Do you suffer from depression diagnosed by a psychiatrist? *
Have you ever had any suicidal thoughts? *
Have you ever been diagnosed with any of the following? *
Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
An eating disorder (e.g. anorexia or bulimia)
Cardiovascular (heart) problems
A stroke
Kidney or liver problems
Thyroid carcinoma
Pancreatitis
None of the above
Do you have a family history of Medullary Thyroid Carcinoma (MTC)? *
Are you pregnant, breastfeeding or planning on conceiving? *
Do you have any physical conditions that prevent you from exercising? *
Do you take any other medicines including prescription, over-the-counter or recreational drugs? *
Do you have any allergies? *
Have you ever had any medical conditions or surgery not previously mentioned in this form, or is there any further information you would like to provide the doctor? *
Are you comfortable using an injection? *
No, I prefer a tablet
I hereby declare that all the information provided in this form is true and accurate to the best of my knowledge. I understand that any false information may affect the assessment and treatment recommendations.
