Medical History Form

This assessment is crucial for you weight loss consultation. Please be honest with your answers abd about your current medications as it helps our ReNu doctors to prescribe safetly to our clients and provide tailored advice. Please ensure that you read the medicinal information before completing the assessment.

ABOUT YOU:

Full Name*

First NameLast Name

E-mail Address*

example@example.com

Phone (Mobile)*

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Address*

Street Address

Street Address Line 2

City

Post Code

Date of Birth*

DayMonthYear

Where did you hear about us?*

Google / websiteSocial MediaBusiness card / flyerFriend / Client recommendation

Name of your GP

GP Surgery / Address*

GP Surgery Phone Number*

What sex were you assigned at birth?*

Are you pregnant, breastfeeding or trying to conceive (now or in the near future)?*

Yes, I'm currently pregnantYes, I'm currently breastfeedingYes, I'm trying to conceiveNo, none of the above

Are you aged between 18-74?*

YesNo

What is your height? (cm)*

What is your current weight? (kg). It is really important you give us an accurate up-to-date measurement. You may be asked to provide evidence of your current weight.*

What is your ethnicity? (This will help our doctor gain a better idea about your risk in relation to your weight).*

Have you ever had any of the following conditions? Please tick all that apply:*

Heart FailureKidney impairmentPancreatitis (current or previous issues)History or family history of Thyroid cancer, medullary thyroid cancer or MEN2Gallbladder or bile duct issues?Liver impairmentNone of the above

Do you have diabetes?*

I have Type 1 DiabetesI have Type 2 DiabetesNo

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 ever made yourself sick (vomit) to control your shape or to lose weight?*

YesNo

Have you ever taken laxatives in order to lose weight?*

YesNo

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?*

YesNo

Would you say that food or image dominates your life?*

Food, yesImage, yesFood and image, yesNo, neither

Do you ever eat in secret?*

YesNo

Do you smoke? *

Are you taking any prescribed medications, over the counter medicines or any dietary / herbal supplements?

YesNo

Please list all medications / supplements

Do you have any allergies?

YesNo

Please provide more information below:

Have you had any surgery in the past 3 months?*

YesNo

Please provide more information below:

Have you ever or do you currently experience an eating disorder (e.g. anorexia, binge eating disorder or bulimia)?*

YesNo

Please provide more information below:

How much exercise do you undertake each week?*

Less than 60 minutes60-180 minutesMore than 180 minutes

Do you drink alcohol? *

If Yes, how many units of alcohol to you consume on a weekly average?

Are you currently using any weight loss treatment (including Wegovy, purchased from ourselves or elsewhere)*

YesNo

What weight loss treatment are you currently using?*

What dose of weight loss medication are you currently taking?

(mg per day or week)

How long have you continuously used your weight loss treatment?*

How much weight have you lost since starting your treatment?*

Kg

Is there any other information you feel would be useful for our ReNu doctors to know about*

YesNo

Please provide more information below:

ACKNOWLEDGEMENTS: To ensure you understand key information about your treatment, read the below statements carefully and acknowledge understanding.

I understand that Wegovy is used as an injection under the skin (subcutaneous injection). I will not inject it into a vein or muscle. The best places to give the injection are the upper arms, stomach or upper legs. I will ensure to drink plenty of fluids to avoid dehydration. I can find detailed instructions on using Wegovy in the Patient Information Leaflet in the box.I understand that the best an safest weight loss outcomes are achieved by slowly and carefully titrating the dose over a 16-week period and i should try to follow the dose escalation schedule to achieve the maximum benefit from the medication.I understand that if I must place an order for my next dose of Wegovy at least 10 days in advance of the required date of next dose.I understand that if I experience any troublesome side effects from Wegovy, I can contact the ReNu team, contact my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient information leaflet.I confirm this treatment is for me, and I consent to this treatment. I confirm that all the above information is truthful and accurate. I agree to inform the ReNu Medical Aesthetics team of any change to my health as soon as possible, as I understand this could impact on suitability of the medication I am prescribed. If Wegovy does not help me realise my weight loss aims, I will consult my GP for further advice. I take responsibility to inform ReNu Medical Aesthetics and/or my own regular doctor of any change in circumstances

Signature

Date

WEIGHT LOSS INJECTION