• ReNu Weight Management Medical Assessment Form

  • This medical assessment helps me understand your health, weight history and current treatment so I can assess whether weight-management medication is appropriate and prescribe safely. Please answer the questions as accurately and completely as possible.

     

    ABOUT YOU

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  • Where did you hear about us?*
  • ReNu recommends informing your GP of any prescribed weight-management medication to support safe, joined-up medical care. Do you consent to ReNu informing your GP about your weight-management treatment?*
  • Are you pregnant, breastfeeding or trying to conceive (now or in the near future)?*
  • What is your current height and weight? Please provide accurate, up-to-date measurements..*
  • Have you ever had any of the following conditions? Please tick all that apply:*
  • Do you have diabetes?*
  • Do you have any of the following weight-related health conditions? Please tick all that apply.*
  • Have you had any surgery in the past 3 months?*
  • Have you previously experienced significant weight regain after dieting or weight loss?
  • Have you ever made yourself vomit in order to control your weight or shape?*
  • Have you ever used laxatives in order to lose weight?*
  • Do you ever feel that you lose control over how much you eat, for example eating an unusually large amount with a sense of being unable to stop?*
  • Have concerns about food, eating, weight or body image had a significant impact on your wellbeing?*
  • Do you ever eat in secret because of concerns about how much or what you are eating?*
  • Have you ever been diagnosed with, or do you currently experience, an eating disorder such as anorexia nervosa, bulimia nervosa or binge-eating disorder?
  • Are you currently taking any prescribed medications, over-the-counter medicines, or dietary/herbal supplements?
  • Do you have any allergies?
  • Are you currently using, or have you previously used, any medication or treatment to help with weight loss?*
  • Which treatment(s) have you used? Please tick all that apply*
  • Have you experienced any significant side effects or problems with previous or current weight-loss treatment?*
  • Do you smoke cigarettes?
  • Do you vape?
  • Do you drink alcohol?
  • How would you describe your current sleep quality?

  • Declaration

    Section 8 of 8
  • Is there any other information you feel would be important for the ReNu doctor to know when assessing your suitability for weight-management treatment?*
  • Please confirm:
  • Date
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    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: