Caresmetics Weight Management assessment Form

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Zero Maker
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Hi, let's confirm your email address please* This field is required.
example@example.com
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What is your Name?* This field is required.
First Name
Last Name
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Hi, {fullname:first}! What is your mobile number?* This field is required.
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By ticking below, you consent for Caresmetics and partners to contact you regarding weight management and other services* This field is required.
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How did you know about Caresmetics Weight management services
Website
Search Engine (e.g. Google etc)
Social media
Referred by a friend
Other
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Name of the person who recommended Caresmetics so we can say thank you
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How did you know about Caresmetics?
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Today Date
Date
Day
Month
Year
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Date of Birth* This field is required.
Date of Birth
Day
Month
Year
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United Kingdom
United Kingdom
Country
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Gender* This field is required.
Male
Female
N/A
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Are you pregnant, breastfeeding or trying to get pregnant?* This field is required.
Yes
No
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What measurements do you prefer?* This field is required.
Metric (cm,kg)
Imperial( feet, stones, etc)
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Weight in Kg* This field is required.
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Height in cm* This field is required.
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Square height
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Height
Feet
Inches
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Inches
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Weight (Stones , lbs)
Stones
lbs
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Pounds
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BMI (Metric)
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Inches squared
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BMI
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Please answer questions in the following section so that we can better know about your medical conditions. Click Next to continue.
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Do you have or had in the past any of the following medical conditions?* This field is required.select all that apply
No medical conditions
Diabetes
Thyroid Problems
Kidney Problems
SEVERE gastro-intestinal problems
Liver Problems
Mental health problems
Other medical conditions
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Tell us about your medical conditions please including your medications* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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{fullname:first}, What type of Diabetes do you have?* This field is required.
Type one
Type 2
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Are you taking Insulin?* This field is required.
Yes
No
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Have you, or anyone in your immediate family ever had thyroid cancer?* This field is required.
Yes
No
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{fullname:first} do you take any medications regularly?* This field is required.
YESNO
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Please list all medicines and what they treat.* This field is required.
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Do you have any known allergies?* This field is required.
Yes
No
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Please list your allergies* This field is required.
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Upload blood tests that we need to know about egg thyroid tests or cholesterol levels
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'YES' below to give us your permission to do so.* This field is required.
Yes
No
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Please provide full contact details for your GP* This field is required.
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I confirm that I have answered all the above questions truthfully* This field is required.
Yes
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Please tick to confirm that you agree with all and each statement* This field is required.
Should I experience any changes in my medical history, I will immediately inform the clinic
Should I experience any changes in my medical history, I will immediately inform the clinic
I agree to record my daily food intake and physical activity
I agree to follow the advices and guidelines provided
I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment
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I confirm that no guarantees for weight loss have been given and that results will vary from individual to individual. I am also aware that around 1 - 2% of people do not respond to treatment, but the reason for this is unknown, and I accept this possibility* This field is required.
Yes
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How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?* This field is required.
0 : Not at all satisfied
1 : Slightly satisfied
2 : Somewhat satisfied
3 : Quite satisfied
4 : Extremely satisfied
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Acknowledgement* This field is required.Almost all injectable weight loss medications are used off license
I confirm
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Thanks {fullname:first}

Your BMI is below the treatment line.

Thanks a lot for filling out the questionnaire
Should be Empty: