Health & Weight Assessment

1

Full name* This field is required.

First Name

Middle Name

Last Name

2

Date of birth* This field is required.

Date

3

Email address* This field is required.

example@example.com

4

Phone number* This field is required.

Please enter a valid phone number.

5

London borough / postcode

6

Current weight (kg)* This field is required.

7

Height (cm)* This field is required.

8

BMI

9

Diagnosed with type 2 diabetes?* This field is required.

Yes

No

10

If yes, please provide details about your type 2 diabetes diagnosis, such as duration of condition etc.

11

History of pancreatitis?* This field is required.

Yes

No

12

If yes, please provide details about your pancreatitis history.

13

Personal or family history of thyroid cancer (medullary thyroid carcinoma)?* This field is required.

Yes

No

14

If yes, please provide details about the thyroid cancer history.

15

History of retinopathy or maculopathy?* This field is required.

Yes

No

16

If yes, please provide details, such as date of eye screening and the scores.

17

History of cardiovascular disease, heart attack, or stroke?* This field is required.

Yes

No

18

If yes, please provide details about your cardiovascular history.

19

History of eating disorders?* This field is required.

Yes

No

20

If yes, please provide details about the eating disorder history.

21

Known kidney or liver conditions?* This field is required.

Yes

No

22

If yes, please provide details about the kidney or liver condition(s).

23

Are you currently taking any prescribed medications?* This field is required.

Yes

No

24

If yes, please list your prescribed medications and dosages

25

Are you currently taking any supplements or over-the-counter medications?* This field is required.

Yes

No

26

If yes, please list your supplements or over-the-counter medications

27

Do you have any known drug allergies?* This field is required.

Yes

No

28

If yes, please list your drug allergies and any known reactions

29

Main goal* This field is required.

Lose body fat

Improve metabolic health markers

Both

Other

31

How long have you been trying to address your weight?* This field is required.

32

If any, what kind of support would you like from Rijaal Health?

33

Exercise frequency per week* This field is required.

35

Current diet* This field is required.

Fairly healthy

Needs work

Poor

Very poor

36

Alcohol units per week* This field is required.

37

Sleep rating* This field is required.

38

I confirm that the information provided above is accurate to the best of my knowledge.* This field is required.

Confirmed

39

I understand that this assessment does not guarantee that a prescription will be issued. In the case that treatment is successfully agreed upon, the cost of the consultation will be redeemed against the cost of treatment.* This field is required.

Understood

40

I consent to Rijaal Health storing and processing my health data for clinical assessment, in line with the Privacy Policy, and I understand this consent is required for GDPR purposes.* This field is required.

I consent