INITIAL WEIGHT LOSS APPOINTMENT

Thank you for booking a weight loss appointment with me. If you can answer a few questions beforehand, it will help me ensure that we get the best from our appointment and achieve what you need for your weight and health. Any data you submit are protected by Jotforms - a secure survey system with GDPR and HIPAA compliance. And, of course, I'm bound by professional confidentiality, so would not share your data with anyone, without your permission.

Please note, this may not constitute a comprehensive medical assessment as I do not have access to your full medical records. Your own doctor is best placed to provide personal medical advice and you should involve your own doctor before making any significant changes to your lifestyle. I recommend you also inform them of any advice I provide regarding weight management, to ensure your medical records are updated, particularly if I recommend or prescribe medication. You can email me at any time if you would like me to remove your data from the system.
Do you already know how you want to tackle your weight?

not sure what to do and looking for general assessment and advice.considering weight loss medication with support.Other
Date and time of booked appointment

DayMonthYear
Date
24 Hour Clock Minutes
Name*

First NameLast Name
Email*

Confirmation Email
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Date of birth*

DayMonthYear
Date
Registered sex at birth

FemaleMaleOther / prefer not to say
Telephone number*
How much do you weigh? Would you prefer to give your answer in....*

stones / poundspounds onlykilograms
Your weight in stones
Please check your answer is correct
and pounds
Your weight in pounds is
Please check your answer is correct so I can use it for further calculations
Your weight in kg is*
Please check your answer is correct so I can make accurate calculations
What is your height? Would you prefer to give your answer in.....*

centimetresfeet and inches
Your height in feet
please check your answer is correct
and inches
Your height in centimetres is*
please check your answer is correctly given in centimetres
Body Mass Index (BMI), a ratio of your weight to your height, is:
BMI represents:

within normal range, but that doesn't always mean that you have a healthy fat distribution if you carry your weight around the middle.classed as within the overweight category, meaning it won't take too many small changes to get things moving in the right direction again.classed as within the obese category which means that you are doing the right thing in addressing your weight issues now.classed as morbid obesity - not a nice term but means that you are doing the right thing in tackling your weight now to reduce the risk of health problems.

Waist-to-hip ratio

This is a helpful way for me to work out whether your weight may be affecting your health so please find a tape-measure. Your waist is halfway between your lowest rib and the top of your pelvic bone. Your hip measurement is the widest point around your buttocks.

Waist measurement in cm*
Hip measurement in cm*
Waist to hip ratio:
Waist to hip ratio represents

lower than the normal limit for women of 0.85, which suggests you are not clearly at risk of metabolic syndrome (combination of diseases such as type 2 diabetes, fatty liver disease, stroke and heart disease) and may make weight management a little easier.higher than the normal limit for women of 0.85, or men of 1, suggesting an increased risk of metabolic syndrome (combination of diseases such as type 2 diabetes, fatty liver disease, stroke and heart disease) and may make weight management a little harder, but very worthwhile.just on the top end of normal meaning further central weight gain could lead to an increased risk of metabolic syndrome (combination of diseases such as type 2 diabetes, fatty liver disease, stroke and heart disease). Weight loss is therefore very worthwhile.
Do you know your blood pressure?*

YesNo
Your blood pressure is shown in the form 120/80 where the upper number is the systolic pressure during heart contraction and the lower number is the diastolic pressure during heart relaxation. Both are important.
Systolic*
Diastolic*
Your blood pressure is :
Blood pressure recommendation

I recommend you check this, and keep an eye on it periodically, via your doctor, local chemist or using a home blood pressure cuff, as it is important to try to keep your blood pressure as close to 120/80 as possible. A high blood pressure may be a sign of metabolic syndrome, which can be associated with being overweight so it's good to know about it.This is at a healthy level which is great. I recommend you keep an eye on it periodically, via your doctor, local chemist or using a home blood pressure cuff, as it is important to try to keep your blood pressure as close to 120/80 as possible to avoid future health problems. Managing your weight will help maintain a healthy blood pressure too.This is a little higher than it could be, but it can vary during the day or with stress. I recommend you check it again and keep an eye on it periodically, via your doctor, local chemist or using a home blood pressure cuff. Try to keep your blood pressure as close to 120/80 as possible to reduce future health problems - managing your weight will help. If repeated values of 140/90 or above, you should ask your own doctor about whether any treatment is required.
Health problems?*

I have current or past health problemsI have no health problems of note
Do your current or past health problems include any of the following? (tick where appropriate)*

type 2 diabeteshigh blood pressureheart problemshigh cholesterolsleep apnoeafatty liver disease or other liver problemkidney problemsnone of the above
Or these health problems?*

gallstonespancreatitis or other disease of pancreasacid refluxproblems with stomach emptying (gastroparesis)inflammatory bowel diseasethyroid diseasenone of the above
Or these health problems?*

Benign intracranial hypertensionFertility problemsCurrent or previous cancerNone of the aboveOther
Please clarify the type of cancer
Are there any health problems that may run in the family that concern you?*

YesNo
Please explain more*
Current or past medical history and family history of note*
There is no current or past medical history of note and no relevant family history. Or Medical history includes.......Family history includes.
Social history*
e.g occupation, family support or stressors.
Suitability for weightloss medication

There is no existing or family history to preclude GLP-1 agonists.I have some concerns about your suitability for GLP-1 agonists.
Are you on any medication?*

YesNo
Do you take any of the following?*

Blood pressure drugsAnti-depressantsThyroid tabletsRegular painkillersContraceptive pillHRTIndigestion / acid reflux drugsDiabetic medication e.g tablets or insulin injectionsOther
Do you have any allergies?*

YesNo
Please provide specific details of the medication you take or of any allergies:
Name and dose of medication taken and any allergies:
e.g. Medication, as described, includes lansoprazole 30mg o.d., paracetamol 1g t.d.s. No allergies reported.
Do you think you may be struggling with any hormonal issues?*

Yes, I think I do have hormonal imbalanceNo, I think I'm ok
Do you experience any of the following?*

I have irregular periods or no periods at allI am having difficulty getting pregnantI have painful or heavy periodsI am putting on more weight around the middleI am struggling with low mood, anxiety, forgetfulness or motivationI am losing my sex-driveI am sleeping badlyI am suffering from hot flushes, cold sweats or night sweats·I wonder if I may be heading for the menopauseI have already hit the menopauseNone of the above
Do you experience any of the following issues?*

I have excessive hair growth on the face, chest, back or buttocksI am losing hair from my headI have oily skin or acneI have been told I have PCOS (polycystic ovary syndrome)People in my family have PCOS·None of the aboveOther
Do any of the following apply to you?*

My female partner is having difficulty getting pregnantI am putting on more weight around the middleI am struggling with low mood, anxiety, forgetfulness or motivationI am losing my sex-driveI am sleeping badlyI am having difficulty initiating or maintaining an erectionI am losing muscle massNone of the above
Hormonal Status
e.g. You are in perimenopause but appear stable on your HRT. or You do not appear to have any hormonal issues at present or You may well be perimenopausal and I suggest discussing this with your GP as HRT may well be worth considering or You are in perimenopause and on HRT but still appear to have some hormonal symptoms which may benefit from some adjustments to your HRT or whatever is relevant.
What's your take on your eating?*

I am confused by all of the information out there about healthy eatingI seem to have lost touch with normal eatingI'm too busy or not that interested in cooking from scratchI struggle with managing hungerMy eating has caused me psychological problems like depression, anxiety, self-loathing or guilt.I often have seconds and find it hard to stop eatingI'm a bit of an emotional eaterI snack all the timeI often crave sugary food and drinkNone of the above
Have you ever been on a diet?*

YesNo
What diets have you tried?*

Slimming WorldWeightWatchersAtkinsDukanLighterLifeRosemary ConleyThe Cambridge Diet or other shake dietsJuice Detox/Juicing5:2 / fasting dietSlimFastLow carb / ketoOther
Why have diets failed for you in the past?*

Can you give an indication of a typical WEEKDAY eating pattern? Fill any that apply. Be as honest as possible to help me advise as best I can!

	Food / drink
Breakfast
Mid-morning
Lunch
Mid-afternoon
Dinner
Evening

Can you give an indication of a typical WEEKEND eating pattern? Fill any that apply. Be as honest as possible to help me advise as best I can!

	Food / drink
Breakfast
Mid-morning
Lunch
Mid-afternoon
Dinner
Evening

Weight struggles - food:
How much exercise do you get - formal or otherwise?*

Sedentary e.g. work at a desk job and do very little exercise or houseworkLightly active e.g. go for long walks 1–3 days per week or do housework like cleaning and gardeningModerately active e.g. moving most of the day and/or exercise with a moderate amount of effort, 3–5 days of the weekVery active e.g. vigorously exercising or playing sports most daysExtra active e.g. vigorous exercise or sports 6–7 days of the week plus a job which requires physical exertion
Do you feel there are any particular barriers to you being more active*

YesNo
Please tell me more*
Weight struggles - exercise:
Do you have any concerns about your sleep?*

YesNo
Where are your concerns?*

I often fail to get a good night’s sleepI feel tired a lot of the timeI snore and wake up several times at nightI often fall asleep during the dayI find it hard to get up in the morningI find it hard to get off to sleepOther
Do you drink alcohol?*

YesNo
Please tell me more*

I drink alcohol on most daysI tend to avoid alcohol during week but catch up at weekends!I usually have more than 2-3 alcoholic drinks at a timeI would find it hard to stop drinking for a monthI worry that alcohol may be affecting my health, work or relationshipsI have been told that I drink too muchNone of the above apply to me
Do you currently smoke or vape?*

YesNo
Do you generally feel cheerful about life?*

NeverRarelySometimesOftenAlways
Do you feel you have been thinking clearly?*

NeverRarelySometimesOftenAlways
Are you feeling good about yourself?*

NeverRarelySometimesOftenAlways
Have you generally been feeling confident?*

NeverRarelySometimesOftenAlways
What were the real triggers that made you ask for help? The more specific you can be, the more I can ensure I provide the right help.
My reason for seeking help is.......*
Weight struggles and concerns - sleep stress mental health and other
Other recommendations*
RECOMMENDATIONS
Finally

I will send you further information regarding medication. Please take time to read through and, if you want to go ahead then please follow the next steps as outlined, including returning a signed consent form. Please look out for a separate invitation to an e-sign document which may occasionally end up in spam. Feel free to contact me for a further chat if any clarification is required before signing the consent form.I recommend you share this clinic letter with your own doctor - please feel free to print off a copy for him or her.And, do please let me know if I can answer any other questions - you can email me or contact me via the website and I'll respond as soon as I can.
Decision

General Advice givenWill consider weight loss programmeSuitable for and wants to consider medication
Date of letter

DayMonthYear
Date
Email

General LetterLetter plus wegovy infoLetter plus CGMNo automatic email
Does patient need consent form emailed?

If so click here

https://tests.breatheassured.com/sign/233196970555062/send
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