Weight Loss Assessment Form

Your Full Name*

First NameLast Name
Your mobile phone Number*
Enter Your Phone NumberFormat: 00000000000.
Your E-mail*
example@example.com
D.O.B*

DayMonthYear
Preferred way of communication*
Address*

Number and Street Address

Street Address Line 2

City

Postal Code
Occupation*
Typical weekly activity /exercise*
- Please complete the medical questions below.
- Please tick any you are aware of. - Any you are unsure of make a note and we can discuss in your consulation.
- You will have the opportunity to list any medication your are taking and what it is used for further in the questionairre. - Please provide as much detail as possible.
Your Weight*
Your Height*
Your Waist: (if known)
Measuring your waist is a good way to check you're not carrying too much fat around your stomach, which can raise your risk of heart disease, type 2 diabetes, cancer and stroke.
Your target weight*
Do you have any of these conditions?*

Alcoholic/substance misuser within one year of recoveryAnti-obesity medicationSerious illness, trauma or surgery (within the last three monthsSerious mental health episode; such as schizophrenia, delusional disorder, psychotic episode, bi-polar disorder (within the last six months)Current active anorexia, bulimia, or currently undergoing treatment for any eating disorderHeart failure/attack, arrhythmia, valve disease requiring treatment (within the last three months)MAOI medicationStroke or TIA (within the last three months)Pregnant, breastfeeding or given birth in the last three monthsYes (please specified from the list above)No, I don't have any of them
Requires MEF*

Diabetes Type 1Diabetes Type 2 (controlled by more than Metformin)Gastrical surgical procedures (within one year)
Step 4 minimum monitoring letter*

Fertility medication
Step 3 minimum*

smoking cessation medication (such as Champix)Stomach ulcerKidney stones
Step 1B minimum*

Cancer in remissionEpilepsyPorphyriaDiabetes InsipdusRheumatoid arthritis treated with medicationSpinal conditions (such as sciatica, spondylitisis, scoliosis) treated with medicationNeuro/muscular conditions (such as MS, fibromyaldia)AnaemiaAntibiotic medicationConstipationCrohn's disease, ulcerative colitis, IBSDiverticular diseaseGall stonesPain relief (moderate to strong)Vertigo
Step 1b minimum and monitoring letter*

kidney disease/failureLiver disease/failureMental health disorders (stable)Angina/Arrythmia (stable)GoutAnit-coagulant medication (such as warfarin)
Any step and monitoring letter*

Chloresterol medicationDiabetes Type 2 (controlled by diet and meformin and/or sitagliptin)Diuretics (Water tablets)Hypertension (high blood pressure)Thyroid medication
Do you have any other medical conditions?*

YesNo
What are the medical conditions: *
None of options above apply

None of the options above
Do you take any Medications?*

YesNo
Details - Medications - dosages and frequency:
If you have answered yes, please write all medications or pills you are taking.
Do you have any allergies or intolerances?*

YesNo
Details - Allergies or Intolerances:
If you have answered yes, please give more details.
How did you hear about me?*
Other
Please leave any other information that you would like to share.
Signature*

I declare that the information given is correct. I consent to my Consultant contacting me at any point regarding my weight loss journey.
Should be Empty: