Weight Management Assessment Form
Thank you for your enquiry, please can you complete the following for us to schedule an initial consultation for you
How did you hear about us?
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Top Dr
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GP Referral
Psychiatry Referral
Insurance Referral
Other Healthcare Professional
Friend/Family Member
Internet search
Social Media
Other (please specify)
Please specify how you heard about us
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Client Information
Full Name
*
Mr.
Mrs.
Ms.
Dr.
Miss.
Other.
Title
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
What is your age?
Email Address
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example@example.com
Contact Number
*
Format: 00000000000.
Your address
*
Street Address Line 1
Street Address Line 2
Town/City
County
Postal
Please upload photo id - such as passport or driving license
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What is your gender?
*
Please Select
Male
Female
Non-Binary
Other
Prefer not to say
Are you pregnant or any possibility of you being pregnant?
*
Please Select
Yes
No
Will you be trying to concieve in the next 3 months?
*
Please Select
Yes
No
Are you currently breastfeeding?
*
Please Select
Yes
No
What is the date of your last menstrual period?
*
-
Day
-
Month
Year
Date
If your last period was more than one month ago, please explain why
Weight in KG
Height in CM
BMI
https://rb.gy/79enk3 (use this link to get your BMI - copy and paste into a new page)
Contacts
Next of kin
*
Please add name, phone number and relationship
Name of your GP
*
GP Email address
Surgery address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you give consent for us to write to your GP for reasons such as medication details?
*
Please Select
Yes
No
Do you consent to receiving emails and/or calls for welfare checks, treatment plan discussions, or other clinic-related matters?
*
Please Select
Yes
No
About your health
Please be aware that it is important to give truthful information about your medical history
Do you suffer from any heart problems?
*
Please Select
Yes
No
Please give details
Do you suffer from any thyroid problems?
*
Please Select
Yes
No
Please give details on any thyroid problems
Do you currently, or have you ever had?
*
Pancreatitis
Kidney problems
Liver problems
Inflammatory bowel disease
Diabetes
Mental Heath problems
Eating disorder
Any other medical problems
None of the above
Do you have or have you had Epilepsy/Seizures/Blood clots?
*
Epilepsy
Seizures
Blood clots
None of the above
Please give details on problems
Are you currently taking any medication?
*
Yes
No
Please list them.
Do you have any medication allergies?
*
Yes
No
Not Sure
If yes please specify:
Do you use any kind of illegal drugs or have you ever used them?
*
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
Do you smoke?
*
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Enter your preferred date and time of day for your initial consultation appointment please note this is not a confirmed date.
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How many units of alcohol do you drink on a typical day when you are drinking?
1-2
3-4
5-6
7-9
10+
Your weight loss journey
How many calories do you consume per day?
Less than 1000
1000-1500
1501-2000
2001-2500
2500+
Do you eat three meals a day?
Please Select
Yes
No
Declaration & Consent
I confirm that I have answered all of the health questions truthfully
Yes
Should I experience any changes in my medical history, I will immediatley inform the clinic
Yes
I agree to record my daily food intake and physical activity
Yes
I agree to the guidelines provided
Yes
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 not everyone responds to the drug and I accept this possibility
Yes
I agree to read the client leaflet before starting
Yes
I wish to commence the programme if I am found to be a suitable candidate following my consulation, and I consent to treatment
Yes
Signature
CLIENT HEALTH QUESTIONNAIRE-9
PHQ 9 /27
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot, more than usual
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
Several days
More than half the days
Nearly every day
PHQ-9 Total
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Hospital Anxiety and Depression Scale
Do not take too long over your replies: your immediate reaction to each item will probably be more accurate than a long thought-out response.
Anxiety
/20
I feel tense and 'wound up'
*
Most of the time
A lot of the time
Time to time, occasionally
Not at all
I get a sort of a frightened feeling like something awful is about to happen
*
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn't worry me
Not at all
Worrying thoughts go through my mind
*
A great deal of the time
A lot of the time
From time to time, but not too often
Only occasionally
I can sit at ease and feel relaxed
*
Definitely
Usually
Not often
Not at all
I get sudden feelings of panic
*
Very often indeed
Quite often
Not very often
Not at all
I feel restless as if I have to be on the move
*
Very much indeed
Quite a lot
Not very much
Not at all
I get a sort of frightened feeling like 'butterflies in the stomach'
*
Not at all
Occasionally
Quite often
Very often
HADS-A Total
Depression
/21
I still enjoy the things I used to enjoy
*
Definitely as much
Not quite so much
Only a little
Not at all
I can laugh and see the funny side of things
*
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
I feel as if I am slowed down
*
Nearly all of the time
Very often
Sometimes
Not at all
I have lost interest in my appearance
*
Definitely
I don't take as much care as i should
I may not take quite as much care
I just take as much care as ever
I feel cheerful
*
Not at all
Not often
Sometimes
Most of the time
I look forward with enjoyment to things
*
A much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
I can enjoy a good book or radio or TV programme
*
Often
Sometimes
Not often
Very seldom
HADS-D Total
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General Anxiety Disorder
GAD-7 /21
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
*
Not at all sure
Several days
Over half the days
Nearly every day
Not being able to stop or control worrying
*
Not at all sure
Several days
Over half the days
Nearly every day
Worrying too much about different things
*
Not at all sure
Several days
Over half the days
Nearly every day
Trouble relaxing
*
Not at all sure
Several days
Over half the days
Nearly every day
Being so restless that is hard to sit still
*
Not at all sure
Several days
Over half the days
Nearly every day
Becoming easily annoyed or irritable
*
Not at all sure
Several days
Over half the days
Nearly every day
Feeling afraid as if something awful might happen
*
Not at all sure
Several days
Over half the days
Nearly every day
GAD-7 Total
Thank you
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