Wellth | Patient Assessment

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Date of Birth* This field is required.

Date

4

Phone Number* This field is required.

Area Code

Phone Number

5

What is your current weight?* This field is required.In kilograms (kg)

6

How tall are you?* This field is required.In centimeters (cm)

7

What are you seeking support for? * This field is required.

8

Are you currently taking weight loss medications?* This field is required.E.g. Ozempic, Wegovy, Mounjaro, Saxenda, Xenical / Alli

Yes

No

I'm considering taking them

Prefer not to say

9

If you are taking weight loss medication, please note which one below.* This field is required.

10

What weight loss strategies have you tried before?* This field is required.

Slimming World / Weight Watchers

Noom

Fasting

Calorie Counting

Personal Training / Exercise

Other

11

If you chose "Other" - please provide further details.* This field is required.

13

To make sure we are supporting you in the safest way possible, please choose any of the following statements that apply to you.* This field is required.

I am pregnant

I have diabetes

I am under the age of 18

I have chronic kidney disease and require a special kidney diet

I currently have an eating disorder or have received treatment in the past for an eating disorder

Prefer not to say

14

Are you looking for a structured weight loss program or single appointments?* This field is required.

Weight loss program

Single appointments

Not sure