Weight Loss Risk Assessment Form
About You
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Gender
*
Male
Female
NHS Number (if known)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
What is your ethnicity?
*
Asian or Asian British
Black, Black British, Caribbean or African
Middle Eastern
Mixed or multiple ethnicities with an Asian, Black or Middle Eastern background
White
Other
Name of your General Practice
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
About your health
What is your height (in metres)?
*
What is your weight (in kg)?
*
What is your waist circumference (in cm)?
*
What is your heart rate (beats per minute)?
*
Do you have any of the following conditions?(please tick all that apply)
*
Prediabetes
Heart disease
High blood pressure
Obstructive sleep apnoea
Not Applicable
Do you have any of the following conditions? (please tick all that apply)
*
Type 1 & 2 Diabetes
Diabetic gastroparesis.
Inflammatory bowel disease.
Ketoacidosis
Obesity secondary to endocrinological oreating disorders or to treatment withmedicinal products that may cause weightgain
Severe renal impairment
Severe hepatic impairment
Cholelithiasis and cholecystitis (include history),
Thyroid disease or medullary thyroid cancer (include history)
Any eating disorders
Severe gastrointestinal disease, e.g. severe gastroparesis, chronic malabsorption syndrome
Gall bladder problems or gallstones
Had bariatric surgery in last 12 months
Not Applicable
Have you ever had an allergic reaction to Wegovy, Semaglutide, Mounjaro, Tirzepatide, Saxenda, Liraglutide, Orlistat, Xenical, or their excipients listed in the SPC?
*
Yes
No
Not Applicable
If Yes please provide details
If female: Are you currently pregnant?
*
Yes
No
Not Applicable
If female: Are you currently breastfeeding?
*
Yes
No
Not Applicable
Are you currently trying to conceive?
*
Yes
No
Not Applicable
If Yes please provide details
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
*
Yes
No
Not Applicable
If Yes please provide details
Are you taking any of the following medications? (please tick all that apply)
*
Amiodarone
Carbamazepine
Ciclosporin
Clozapine
Digoxin
lodine salts and/or Levothyroxine
Oral Methotrexate
Oral Contraceptives
Phenobarbital
Phenytoin
Tacrolimus
Theophylline
Warfarin
Steroids
Medications that treat HIV
Medications that lower blood glucose
Fat soluble vitamins (A, D, E and K)
Medications that treat epilepsy
Not Applicable
Step Up or Maintenance dose
Are you currently taking any of the following weight loss medications: Orlistat, Mysimba, GLP-1 receptor agonists: Wegovy, Mounjaro, Semaglutide, Saxender or Liragluride)?
*
Yes
No
Not Applicable
If Yes please provide details
If Yes, to the above and you have previously started treatment or got the supply elsewhere are you able to provide proof of previous use for example: prescription, label, dispatch note or receipt)?
*
Yes
No
Not Applicable
If yes, may you please upload proof to the above question
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Please provide the date you started taking GLP-1 treatment?
-
Month
-
Day
Year
Date
Please provide the initial weight that you were, when you started GLP-1 treatment (weight in kg)
Please provide the current GLP-1 treatment and specify name of the medication and dose
Have you experienced any of the following side effects? (please tick all that apply)
Gastro-Intestinal side effects e.g. nausea,vomiting, diarrhoea, constipation, bloating, reflux or heartburn
Injection site reaction e.g. swelling, itching or redness
Allergic reaction e.g. rash, itching
Acute Pancreatitis
Bowel Obstruction
Gall bladder problems or gall stones
Dehydration
Not Applicable
Have you been appropriately titrated on the medication in line with the relevant Summary of Product Characteristics (SPC) or protocol, and are you following the correct injection schedule?
Yes
No
Not Applicable
If No, please provide details
Is there a gap (not using the medication more than 4 weeks) in the continuity of your medication supply?
Yes
No
Not Applicable
If Yes, please provide details
Acknowledgement
Do you understand that you will be required to have a video or a face to face consultation with our clinician before the medication can be supplied?
*
Yes
No
Do you understand that GLP-1 injectable weight-loss medication (e.g. Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional contraceptive measures, such as a barrier method (e.g. condoms), or switching to a non-oral form of contraception (e.g. IUD's and implants) for 4 weeks after initiating Mounjaro and for 4 weeks following each dose increase.
*
Yes
No
Do you understand that GLP-1 injectable weight-loss medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?
*
Yes
No
Do you understand the risk of pancreatitis, gall bladder issues, and gallstones associated with these medications, and that abdominal pain should be reported to a doctor?
*
Yes
No
Do you understand that injectable weight-loss medications should not be used in combination with other weight-loss medications?
*
Yes
No
Do you understand that if you develop neck lumps or a hoarse voice while using this medication, you should stop and contact your doctor?
*
Yes
No
Do you understand both weight loss and injectable weight loss treatment have been associated with lowering of mood, if experiencing depression, thoughts of self harm or other menta health issues, you should seek medical advice
*
Yes
No
Can we share this information with your General Practitioner? Providing us with your GP's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We would require you share this treatment with your doctor for him/her to update your medical records
*
Yes
No
Do you agree to the following?
You are aware that GLP-1 receptor agonists can lower your blood sugar, increasing the risk of hypoglycemia
*
Yes
No
You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
*
Yes
No
You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
*
Yes
No
You will inform your doctor about any unusual side effects
*
Yes
No
The treatment is solely for your own use
*
Yes
No
You will read the patient information leaflet supplied with your medication and understands the titration schedule, actions to take if a dose is missed, correct self-injection technique, and proper storage requirements for the medication
*
Yes
No
You will not exceed the maximum prescribed dose
*
Yes
No
You understand that you should follow up with your GP at least once annually for ongoing monitoring and care
*
Yes
No
You confirm you have the capacity to make decisions about your own health
*
Yes
No
.
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