• Intake Form

  • Entry Date
     - -
  • Date of Birth*
     - -
  • Gender*

  • We look beyond just BMI and assess your overall health profile. You are eligible if one or more of the following situations apply to you:

    • BMI of 30 or higher
    • BMI of 25 or higher in combination with a weight-related condition, such as high blood pressure, prediabetes, fatty liver disease, sleep apnea, high cholesterol, PCOS, joint pain, or lipoedema
    • Increased waist circumference of ≥ 102 cm (men) and ≥ 88 cm (women)
    • Previous lifestyle interventions had insufficient or temporary effect
  • Do you smoke?*
  • Type 2 diabetes in father, mother, brother or sister*
  • Cardiovascular disease in father, mother, brother or sister before age 65*
  • Physical activity according to exercise guideline 2017*
  • 0/200
  • Have you previously followed guided lifestyle programs?*

  • What was the result?*
  • I want treatment with:*

  • Which injection suits me?
    See our website for explanation

  • I have recently used one of the following medications:*
  • Preferred location Healthy Weight Clinics*
  • Do you have*
  • Contraception

  • Have you undergone abdominal surgery?*
  • Do you use medication?*
  • I give the doctors of Healthy Weight Clinics permission to share my medical data with my general practitioner:*
  • I give the doctors of Healthy Weight Clinics permission to request my medication data via the National Exchange Point:*
  • I give the doctors of Healthy Weight Clinics permission to use my medical data, recorded in the medical file during treatment, ANONYMOUSLY for scientific research:*
  • Should be Empty: