YOUR STARTING POINT

BEFORE WE START
As previously explained, I am keen to advise on the most effective ways to help weight loss in a healthy, sustainable way. These in-depth questionnaires are based on the questions I ask my own patients in clinic and include some special category data i.e data relating to your health and ethnicity. Any questions asked are relevant in identifying risk factors for obesity and related health conditions to help me, to help you.

These questionnaires and any advice provided as a result are not intended to replace a proper medical assessment as could be provided by your own doctor who has your full medical history. Any general recommendations made during this coaching programme should be checked with your own doctor where appropriate, before proceeding.
Please confirm you have understood the above and are still happy to proceed

Yes, confirmedNo, I am not yet ready to proceed with this coaching programme
Please contact our customer services team if you have further questions or have changed your mind about the coaching programme.
VERIFIED HEIGHT AND WEIGHT MEASUREMENT

Please ensure you are ready to upload photographic evidence of your height and weight alongside verified ID. I will also ask for your waist, hip and blood pressure measurements as detailed on your programme page.
Are you ready to go ahead?

Photo of IDPhoto showing you alongside height measurementPhoto of you with weight measurementSide photo to show body shapeBlood pressure readingWaist and hip measurement30 minutes of free time

BASIC STATS
Name*

First NameLast Name
Age*
Date of birth*

DayMonthYear
Date
Please upload photo ID showing name and date of birth that I can correlate with your weight and height readings for regulatory purposes. Thank you.*

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Ethnicity*

Asian or Asian BritishBlack, Black British, Caribbean or AfricanWhite British or EuropeanMixed or multiple ethnic groupsOther
Email (and validation of email address for security when sending report)*
What WeightLoss Doctor plan are you signed up for?

Weight Loss for Life programme aloneWeight Loss for Life Programme with medication supportOther
Mobile Phone Number*
Please enter country code and omit the first zero
How much do you weigh? Would you prefer to give your answer in....*

stones / poundspounds onlykilograms
Your weight in stones*
and pounds*
Your weight in pounds is
Your weight in kg is*
Please upload a photograph of you on scales showing weight reading. Thank you.*

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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
Please upload a photograph of you alongside a tape measure that confirms your height. Thank you.*

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Please upload a photograph of you in side profile too, so I can assess your weight distribution. Thank you.*

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Body Mass Index (BMI), a ratio of your weight to your height, is:
Your BMI

I'll explain more about BMI and the strengths and weaknesses of it in a forthcoming session. But it is also used to guide eligibility for weight loss medication.

The newer forms of medication can provide a really useful boost as you work through the programme, and are licensed for people with a proven body mass index of 27 and above if White origin (or around 26 and above if Asian or Black origin) as long as they are suitable on a medical assessment. If you would like to learn more with a view to using medication or suggesting it to other family members or friends, please indicate below. Then check your emails for an invitation to join a live session with me on my Weightloss Doctor community platform where I can tell you more and answer any questions you may have. If you are still interested, I can provide you with a personal assessment and a prescription if we both agree it is the right approach for you.
Would you like further information about medication?

Yes please - I would like to see if I am potentially suitable for medication.No thanks - I'm happy to continue with the programme alone.I'm not interested myself, or not eligible, but would like to understand more anyway.
The following conditions may mean you are not suitable for medication. I can advise further whether or not medication may or may not be suitable or safe for you. Please tick any of the following that apply to you.

Under 18 or over 75Pregnant or planning to become pregnantBreastfeedingEating disorder now or in the pastDiabetic gastroparesis (slow stomach emptying in diabetics)Inflammatory bowel disease (e.g. Crohns, Ulcerative Colitis)Congestive heart failureSevere kidney diseaseLiver diseasePancreatitisThyroid tumourNONE OF THE ABOVE APPLY TO ME
METABOLIC HEALTH
Metabolic syndrome describes a cluster of conditions that are often associated with being overweight. However, not everyone who is overweight seems to be at risk of metabolic syndrome. Conversely, not everyone who has metabolic syndrome is overweight.

By determining your risk for metabolic syndrome, you are in a good position to understand why you are struggling with weight loss and what you can focus on to change it.
Have you been told that you have any of the following conditions, which may be an indicator of metabolic syndrome?*

type 2 diabetespre-diabeteshigh blood pressureheart problems or narrowing of the arteries in the legsstroke or TIAfatty liver diseasehigh cholesterolNONE OF THE ABOVE
Have your parents or siblings suffered from any of the conditions?*

YesNoDon't know

Waist-to-hip ratio

Metabolic syndrome is more common in those who have increased fat around the middle compared to their hips, so please find a tape measure so you can measure your waist-to-hip ratio.

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.

I will explain what this means for you later in the programme.

Waist measurement in cm*
Hip measurement in cm*
Waist to hip ratio:
Blood Pressure

High blood pressure may also be an indicator of metabolic syndrome, so it's good to know about it as weight loss is one of the best things you can do to reduce your blood pressure. High blood pressure can increase your risk of heart disease, stroke, diabetes, kidney disease, eye disease and more so it's worth keeping under control. One in four people have high blood pressure without even knowing about it!

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*
Do you have results on any of the following blood tests? (may be on your NHS app)

Blood countLiver testsFat levels, lipid screen or cholesterolHbA1c or fasting blood glucoseNo, I don't have any results available.
Do you know your blood lipid levels?

YesNo
What are your triglyceride levels?

Below 2.3mmol/l non-fastedBelow 1.7mmol/l fasted for 10-14 hours2.3mmol/l or above non-fasted1.7mmol/l or above after fasting for 10-14 hoursDon't know
What is your HDL cholesterol

Over 1.2mmol/l1.2 mmol/l or lessDon't know
GUT HEALTH
Do you have or have you had any of these upper gut diseases or conditions?*

gallstonespancreatitis or other disease of pancreasjaundice (yellowing of skin)Barrett's oesophagus or oesophagitisproblems with stomach emptying (gastroparesis)coeliac diseasehiatus herniacancer in this regionremoval of gallbladder (cholecystectomy)other operations in this upper abdominal regiongastric balloonweight loss surgery (gastric band, sleeve or bypass)NONE OF THE ABOVE
Do you have any of these upper gut (oesophagus or gullet, and stomach) health symptoms?*

acid reflux / indigestionsticking of food when swallowingnausea or vomitingpain in upper abdomenNONE OF THE ABOVE
Do you have any of these lower gut (bowel) diseases or conditions?*

inflammatory bowel disease (ulcerative colitis or Crohn's diseasebowel polypsdiverticular diseasebowel cancerNONE OF THE ABOVE
Do you have any of these lower gut (bowel) symptoms?*

bloatingcramping painsconstipationdiarrhoeableeding when opening bowelsNONE OF THE ABOVE
Do you have any of these food allergies?*

nutsshellfisheggsNONE OF THE ABOVEOther
Do you have any of these food intolerances?*

glutenlactosecertain fruits or vegetablesNONE OF THE ABOVEOther
Do you have any other gut health issues you want to mention? If so, note them down here....
HORMONE STATUS
Biological sex*

FemaleMaleTransitioned / transitioning F:MTransitioned / transitioning M:FOther
Do you have any of the following hormonal conditions?*

Underactive thyroidPolycystic ovary syndrome (PCOS)EndometriosisEndometritis or adenomyosisFibroidsPremature menopause (periods stopped before age 40)Menopause (periods stopped for a year after age 40)NONE OF THE ABOVEOther
Do you experience any of the following symptoms associated with periods (menstruation) or fertility?*

I have painful, heavy or irregular periodsI am having difficulty getting pregnantI have suffered from miscarriagesNONE or NOT APPLICABLE
Do you experience any of the following symptoms associated with perimenopause?*

I am losing my sex-driveI am putting on more weight around the middleI have irregular periods or no periods at allI am struggling with low mood, anxiety, forgetfulness or motivationI am sleeping badlyI am suffering from hot flushes, cold sweats or night sweats·NONE OR NOT APPLICABLE
Do you experience any of the following issues that may be associated with PCOS?*

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 ABOVE
Do you experience any of the following issues that may suggest underactive thyroid?*

I feel the cold more than most peopleMy hair is becoming quite coarseMy skin is really dryI am tired all the time·I am getting constipatedNONE OF THE ABOVE
NUTRITION STATUS
How would you best describe your eating preference?*

omnivore (I eat meat and fish and other foodstuffs e.g.vegetables)pescatarian (I don't eat meat but do eat fish)vegetarian (I eat plant-based meals but do have dairy, eggs or other animal products)vegan (I eat no animal derived products)carnivore (I eat meat and fish only)Other
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'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?*
EXERCISE
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 have any idea of your predicted average daily step count?*

YesNoNot applicable
Average number of steps I do each day is:
Do you feel there are any particular barriers to you being more active*

YesNo
Please tell me more*
Predicted Resting Metabolic Rate
Predicted Total Energy Expenditure
SLEEP
Do you have any concerns about your sleep or daytime tiredness?*

YesNo
What 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 sometimes fall asleep during the dayI find it hard to get up in the morningI find it hard to get off to sleepI have an unusual/irregular sleep pattern due to shift working or other issuesOther
How likely are you to doze off during the day if you are sitting and reading?*

NeverRarelySometimesOften
Or when watching TV?*

NeverRarelySometimesOften
How about if you are sitting, inactive in a public place e.g. cinema or a meeting?*

NeverRarelySometimesOften
Or as a passenger in a car for an hour without a break?*

NeverRarelySometimesOften
Or when lying down to rest in the afternoon, if circumstances permit?*

NeverRarelySometimesOften
Do you think you may doze off if you are sitting and talking to someone?*

NeverRarelySometimesOften
How about when sitting quietly after lunch without alcohol?*

NeverRarelySometimesOften
Or even, in a car or bus, while stopped for a few minutes in traffic?*

NeverRarelySometimesOften
Your Daytime Sleepiness Score is:
STRESS
Do you feel under pressure from any of the following:*

Work or work colleaguesFinancial worriesCaring for kidsCaring for elderly relativesFamily illnessPersonal relationshipsNONE OF THE ABOVEOther
In the last month, how often have you been upset because of something that happened unexpectedly?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you felt that you were unable to control the important things in your life?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you felt nervous and stressed?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you felt confident about your ability to handle your personal problems?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you felt that things were going your way?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you found that you could not cope with all the things that you had to do?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you been able to control irritations in your life?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you felt that you were on top of things?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you been angered because of things that happened that were outside of your control?*

NeverRarelySometimesFairly oftenVery often
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?*

NeverRarelySometimesFairly oftenVery often
Your Stress Score is:
MOOD
Have you had a formal diagnosis of any of the following?*

DepressionAnxietyNONE OF THE ABOVEOther
Have you been feeling optimistic about the future?*

NeverRarelySometimesOftenAlways
Have you been feeling useful?*

NeverRarelySometimesOftenAlways
Have you been feeling relaxed?*

NeverRarelySometimesOftenAlways
Have you been feeling interested in other people?*

NeverRarelySometimesOftenAlways
Have you had energy to spare?*

NeverRarelySometimesOftenAlways
Have you been dealing with problems well?*

NeverRarelySometimesOftenAlways
Do you feel you have been thinking clearly?*

NeverRarelySometimesOftenAlways
Are you feeling good about yourself?*

NeverRarelySometimesOftenAlways
Have you been feeling close to other people?*

NeverRarelySometimesOftenAlways
Have you generally been feeling confident?*

NeverRarelySometimesOftenAlways
Have you been able to make up your own mind about things?*

NeverRarelySometimesOftenAlways
Have you been feeling loved?*

NeverRarelySometimesOftenAlways
Have you been interested in new things?*

NeverRarelySometimesOftenAlways
Do you generally feel cheerful about life?*

NeverRarelySometimesOftenAlways
Your Mood Score is:
OTHER HEALTH CHECKS
Have you ever been diagnosed with any of these health problems?*

Benign intracranial hypertensionCurrent or previous cancer not already recordedChronic fatigue (ME)FibromyalgiaArthritisAutoimmune diseaseNONE OF THE ABOVEOther
Please clarify the type of cancer
Are there any health problems that may run in the family that concern you that you have not already mentioned?*

YesNo
Please explain more*
Are you on any medication?*

YesNo
Do you take any of the following?*

Blood pressure drugsAnti-depressantsRegular painkillersContraceptive pillHRTIndigestion / acid reflux drugsDiabetic medication e.g tablets or insulin injectionsThyroid medicationMedication for polycystic ovariesOther
Do you have any drug allergies?*

YesNo
Please provide specific details of the medication you take or of any drug allergies:*
Do you drink alcohol?*

YesNo
How often do you have a drink containing alcohol?*

NeverMonthly or less2-4 times a month2-3 times a week4 times or more a week
How many units of alcohol do you drink on a typical day when you are drinking?*

0-23-45-67-910 or more
How often have you had 6 or more units on a single occasion in the last year?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you found you were not able to stop drinking once you had started?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you failed to do what was normally expected from you because of your drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you needed an alcoholic drink in the morning to get yourself going after a heavy drinking session?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
Have you or somebody else been injured as a result of your drinking?*

NoYes, but not in past yearYes, in past year
Has a relative or friend, doctor or health worker been concerned about your drinking or suggested that you cut it down?*

NoYes, but not in past yearYes, in past year
Your Alcohol Use Score is:
Do you currently smoke or vape?*

YesNo
AND FINALLLY

What were the 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.......*
Finally, are there any other issues that I haven't covered that you feel are relevant to your own weight struggles? If so, please provide details here so that I can ensure I cover them in the programme in an anonymised way. If your issues are very personal and unlikely to be relevant to others, I will contact you individually with any recommendations.*
All done! Now press the SUBMIT button below.

If you don't get taken to a thank-you page, check back that you have filled in all fields and SUBMIT again. Then check your email for a summary of your key responses for your workbook.
Should be Empty:

BEFORE WE START

BASIC STATS

METABOLIC HEALTH

GUT HEALTH

HORMONE STATUS

NUTRITION STATUS

EXERCISE

SLEEP

STRESS

MOOD

OTHER HEALTH CHECKS

AND FINALLLY

All done! Now press the SUBMIT button below.