Switching Provider Questionnaire

Switching Provider Questionnaire

Please complete all mandatory fields
First Name*
Last Name*
Phone Number*
Email*
example@example.com
info@mshweightloss.co.uk
example@example.com

How would you describe your ethnic background?

What’s considered a healthy weight can be different depending on your ethnic background. Tell us how you describe yourself so we can ensure you’re getting the right care.
Asian or Asian BritishBlack, Black British, Caribbean, or AfricanWhiteMixedArabPrefer not to say

MaleFemale
YesNo

What is your Date of Birth?*

DayMonthYear
Date

What is your weight & height?
Please enter your weight & height
ImperialMetric
BMI
Feet
Inches
Centimetres
Pounds
Kilograms
Body Mass Index (BMI)
Inches to Meter (conversion)
Feet to Meter (conversion)
Pounds to KG (conversion)
CM to Meter (conversion)
Feet & Inches to Meter
Pounds to KG
Centimetre to Meter
Meter Squared
Number (Just to clear when unit of measurement is switched)

Have you been diagnosed with diabetes?
I have diabetes and take medication for itI have diabetes and it's diet controlledI don't have diabetes

Please list any other medical conditions you have.

Our clinicians need to know your full medical history to make sure treatment is safe for you to take.
Other Medical Conditions*

Do any of the following statements apply to you?
I have been diagnosed with a mental health condition such as depression or anxietyI have or have had an eating disorder such as bulimia, anorexia nervosa, or a binge eating disorderNone of these statements apply to me
If any statements apply to you, please tell us your specific diagnosis, when you were diagnosed, and how you manage the condition.*

Please indicate whether you are presently using any medication, such as prescription drugs, over-the-counter medications, or supplements, by selecting all that are applicable to you.
I'm on Levothyroxine or WarfarinOther/ I take more than one prescription medication(if so, please list all medication that you currently take)I don't take any medication
Please list all prescription medication that you currently take.*

Do you have any known allergies? If yes, please list them clearly in the space provided below.

If you do not have any allergies, simply state 'none'
Allergies*

Facebook/InstagramTikTokGoogle or Web SearchDirect Mail or LeafletFriend or Family ReferralOther
Type in your friend or family referral name here:
If other, please describe:

Informing General Practitioner (GP)

Important information to review

Thanks for submitting your assessment. Our nursing team will now review it, and we’ll be in touch soon with the next steps in your application.
Should be Empty: