Answer all assessment questions below
Units
Metric (cm / kg)
Imperial (ft / in / lb)
Height (cm)
Weight (kg)
Height (FT)
Inches (In)
Weight (lb)
BMI
BMI
Email (Required)
example@example.com
DATE OF BIRTH
*
/
Day
/
Month
Year
Date Picker Icon
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Are you in one of the following ethnic groups?
*
White (Includes any white background. For example, British or Irish traveller)
Asian (Includes any Asian background. For example, Bangladeshi, Chinese, Indian, Malaysian or Japanese)
Black (Includes any black background. For example, African, Caribbean or Black British)
Middle Eastern (Includes any Middle Eastern background. For example, Arab or Iranian)
Prefer not to say
Other
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Do you have a weight-related conditions or surgeries?
*
High blood pressure (hypertension)
Asthma, using daily medication
Obstructive sleep apnea (OSA)
Dyslipidemia
High levels of one or more lipids such as cholesterol or triglycerides
Type 2 Diabetes and taking any diabetes medicines
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Do you have any of the following medical conditions?
Gastroparesis
Crohn's disease or ulcerative colitis
Previous or existing pancreatitis
Severe kidney disease
Type 1 Diabetes
Retinopathy
Cancer (currently undergoing treatment or less than 5 years since your treatment has been completed)
Severe liver disease,
liver cirrhosis or liver failure
Heart failure and taking medicines
Gallbladder disease / history of gallstones
Family history of thyroid cancer
Multiple endocrine neoplasia (MEN)
Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia type 2 (MEN2)
Family history of multiple endocrine neoplasia (MEN)
Eating disorder, past or present, e.g. anorexia or bulimia
Suicidal thoughts or self-harm in the last 12 months
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Are you taking insulin for your type 2 diabetes?
Yes
No
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Have you ever had any of the following cardiovascular or surgical conditions?
History of heart attack or stroke
Heart failure
Irregular heart rhythm requiring treatment
Previous bariatric surgery (gastric bypass, sleeve, band)
Chronic Obstructive Pulmonary Disease (COPD)
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Are you pregnant, planning to be pregnant, or breastfeeding?
Pregnant
Planning to be pregnant in next 3 months
Breastfeeding
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Is your blood pressure currently controlled with medication?
Yes
No
I don't take medication for it
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Are you currently taking any weight loss injections?
Yes
No
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Have you experienced any side effects whilst taking weight loss medication?
Yes
No
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Please tell us what side effects you have experienced and how they impacted you
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Which weight loss injection are you currently taking?
Wegovy
Mounjaro
Other
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Which dosage of Wegovy are you currently taking?
0.25mg
0.5mg
1mg
1.7mg
2.4mg
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Which dosage of Mounjaro are you currently taking?
2.5mg
5mg
7.5mg
10mg
12.5mg
15mg
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Date of last injection
*
/
Day
/
Month
Year
Date
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Do you take any of the following medications?
Insulin
Sulfonylureas
Glimepiride (Amaryl), Glipizide (Glucotrol and Glucotrol XL), Glyburide (Micronase, Glynase, Diabeta), Gliclazide, Gilbenclamide, Tolbutamide
DPP-4 inhibitors
Sitagliptin, Saxagliptin, Linagliptin, Alogliptin
SGLT-2 inhibitors
Empagliflozin, Dapagliflozin, Canagliflozin, Ertugliflozin
Other blood thinners taken for any of the following conditions
Von Willebrand Disease, Antiphospholipid Syndrome (APS), Disseminated Intravascular Coagulation (DIC), Factor V Leiden, Protein C Deficiency, Protein S Deficiency
Others
Warfarin, Lithium, Digoxin, Theophylin, Acenocoumarol, Amiodarone, Clozapine, Flecanide, Insulin
None of the above
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Have you tried to lose weight before?
Diet only
Exercise only
Weight loss medication
Bariatric surgery
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Are you currently taking or planning to start an oral hormonal contraceptive?
Yes
No, not taking or planning to start an oral hormonal contraceptive
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Do you have any of these conditons?
Cardiovascular Disease
Hypertension
Hypercholesterolaemka
Chronic Pelvic Pain
Endometriosis
POTS (Postural Orthostatic Tachycardia Syndrome)
Long Covid
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How much alcohol do you drink per week?
None
1–7 units
8–14 units
15+ units
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How much weight are you looking to lose?
Less than 10kg
10–20kg
20–30kg
More than 30kg
I'm not sure
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How did you hear about us?
Instagram
Google
Friend or Family
Doctor
Other
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Sorry
Based on your answers, it looks like you don't qualify for the medicated weight loss programme at this time. Warning: Giving inaccurate information could put your health at risk.
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In review
Based on your answers, your application requires a little more review before we can confirm your eligibility. A doctor from our medical team will assess your responses within 5–7 working days. They may contact you with follow-up questions before a decision is made.Submitting this form is not an approval, it simply starts the review process. We'll be in touch via email.
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