Weight Loss Assessment Form

  • WEIGHT LOSS INJECTION

    Medical Assessment Form

  • This assessment is an important part of your weight loss consultation. Please answer the questions honestly and accurately, including details of any medications or supplements you are currently taking, as this helps the ReNu doctor prescribe safely and provide personalised treatment advice.

     

    ABOUT YOU

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  • Where did you hear about us?*

  • GP Communication

  • With your consent, ReNu Medical Aesthetics may inform your GP of any prescribed weight loss medication to support continuity and safety of care. Would you be happy for the ReNu doctor to inform your GP about your prescribed weight loss treatment if clinically appropriate?
  • Are you pregnant, breastfeeding or trying to conceive (now or in the near future)?*
  • Have you ever had any of the following conditions? Please tick all that apply:*
  • Do you have diabetes?*
  • People with weight-related medical conditions may be prescribed weight loss medicines at a lower BMI than other patients, if suitable. Please let us know if you have any of the following weight-related conditions?*
  • Have you previously experienced significant weight regain after dieting or weight loss?
  • Have you ever made yourself sick (vomit) to control your shape or to lose weight?*
  • Have you ever taken laxatives in order to lose weight?*
  • Do you worry that you have lost control over how much you eat? (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time?*
  • Have concerns about food, eating, weight or body image had a significant impact on your wellbeing?*
  • Do you ever eat in secret?*
  • How would you describe your current sleep quality?
  • Are you taking any prescribed medications, over the counter medicines or any dietary / herbal supplements?
  • Do you have any allergies?
  • Have you had any surgery in the past 3 months?*
  • Have you ever or do you currently experience an eating disorder (e.g. anorexia, binge eating disorder or bulimia)?*
  • How much exercise do you undertake each week?*
  • Are you currently using any weight loss treatment (including Wegovy or Mounjaro, purchased from ourselves or elsewhere)*
  • What weight loss treatment are you currently using?*
  • Is there any other information you feel would be useful for the ReNu doctor to know about*
  • ACKNOWLEDGEMENTS: Please read the following statements carefully and confirm your understanding before proceeding with treatment.
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