Pre-consultation: Weight Management

First name *

Last name *

Email *

Phone *

Date of birth *

What is your current weight? *

Please enter in kg or stones

What is your height? *

Please enter in cm or feet/inches

What is your target weight (if you have one)?

How long have you been trying to lose weight? *

Less than 3 months

3-6 months

6-12 months

1-2 years

2-5 years

More than 5 years

Not actively trying yet

What is your primary motivation for weight loss? *

Health

Appearance

Energy and fitness

Medical advice from a doctor

Fertility

Mobility

Other

Do you make yourself Sick because you feel uncomfortably full? *

This is a validated screening tool. Answering honestly helps us assess your safety.

Yes

No

Do you worry you have lost Control over how much you eat? *

Yes

No

Have you recently lost more than one stone (6.35 kg) in a 3-month period? *

Yes

No

Do you believe yourself to be Fat when others say you are too thin? *

Yes

No

Would you say that Food dominates your life? *

SCOFF screening - 2 or more 'Yes' answers suggests possible eating disorder. This is a screening tool, not a diagnosis.

Yes

No

Have you ever been diagnosed with an eating disorder? *

Yes

No

What is the highest weight you have been as an adult?

What is the lowest weight you have been as an adult?

What was your weight at age 18 (if you remember)?

How would you describe your weight gain pattern?

Gradual gain over many years

Gain after a specific life event

Gain after pregnancy

Gain after starting/stopping medication

Gain after stopping smoking

Gain after menopause

Gain after an injury that limited exercise

Other

Which weight loss methods have you tried before? (select all that apply)

Select all that apply

Calorie counting

Low-carb or keto diet

Intermittent fasting

Commercial programmes (Weight Watchers, Slimming World, etc.)

Very low-calorie diet (VLCD) or meal replacement

Exercise or fitness programmes

Orlistat (Xenical)

GLP-1 medications (Saxenda, Wegovy, Ozempic, Mounjaro)

Bariatric (weight loss) surgery

Other

How much weight did you lose on the GLP-1 medication?

What is the most weight you have lost through dieting?

How quickly did you regain the weight after your diet?

Immediately (within weeks)

Slowly over months

Slowly over a year or more

I kept it off

Do you have a personal or family history of medullary thyroid carcinoma (MTC)? *

ABSOLUTE CONTRAINDICATION - GLP-1 medications cannot be used if you have or have had medullary thyroid cancer, or if it runs in your family.

Yes

No

Not sure

Do you have a personal or family history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)? *

ABSOLUTE CONTRAINDICATION - GLP-1 medications cannot be used if you have MEN2 or a family history of it.

Yes

No

Not sure

Have you had pancreatitis (inflammation of the pancreas)?

GLP-1 medications can increase pancreatitis risk. This is a relative concern depending on how many episodes and when.

Yes

No

Not sure

Do you have gallbladder problems or a history of gallstones?

GLP-1 medications increase the risk of gallbladder problems and gallstone formation.

Yes

No

Not sure

Do you have a history of severe stomach/gut conditions, including gastroparesis?

GLP-1 medications slow stomach emptying and can worsen gastroparesis.

Yes

No

If you have diabetes, do you have diabetic retinopathy (eye damage from diabetes)?

Rapid glucose improvement from GLP-1 can temporarily worsen diabetic retinopathy.

Yes

No

I don't have diabetes

Not sure

Are you currently pregnant or planning to become pregnant?

GLP-1 medications should be stopped at least 2 months before conception.

Yes, currently pregnant

Yes, planning pregnancy within 6 months

No

Not applicable

Do you have type 1 diabetes?

GLP-1 medications for weight loss are not suitable for type 1 diabetes.

Yes

No

Do you have kidney disease?

GLP-1 medications can affect kidney function. Please provide details if yes.

Yes

No

Not sure

Do you have type 2 diabetes?

Yes

No

Do you have thyroid problems?

Hypothyroidism can contribute to weight gain. Weight loss medication may interact with thyroid treatment.

Yes

No

Not sure

Do you have PCOS (polycystic ovary syndrome)?

PCOS often causes weight gain and may benefit from specific weight loss approaches.

Yes

No

Not sure

Do you take long-term corticosteroids or have Cushing's syndrome?

Steroids cause weight gain and may affect weight loss medication.

Yes

No

Do you have sleep apnoea?

Sleep apnoea is linked to weight gain and can be improved by weight loss.

Yes

No

Suspected but not diagnosed

Do you have joint problems or arthritis affecting your ability to exercise?

Yes

No

Do you have heart disease or heart failure?

Some weight loss medications have cardiac benefits; others require cardiac assessment first.

Yes

No

Do you have depression or anxiety?

Some medications for weight loss can affect mood. We want to make sure the approach suits you.

Yes

No

Do you have ADHD or take ADHD medication?

ADHD can involve impulsive eating. Some ADHD medications affect appetite.

Yes

No

Describe your typical daily eating pattern (meals, snacks, portion sizes) *

Do you eat in response to emotions rather than physical hunger?

Never

Sometimes

Often

Almost always

Do you eat late at night after your main meal?

Late-night eating is common and can affect weight loss efforts.

Never

Rarely

Sometimes

Frequently

How many units of alcohol do you drink per week?

1 unit = small glass of wine, 1 shot spirits, or half a pint of beer

What type and how much exercise do you currently do?

Include type, frequency, and duration

What barriers prevent you from exercising more? (select all that apply)

Lack of time

Pain or physical limitation

Lack of motivation

Disability

Fatigue

Cost

Childcare responsibilities

No barriers

How many hours per day are you typically sedentary (sitting/lying)?

Sedentary time is linked to weight gain and health problems.

Less than 4 hours

4-6 hours

6-8 hours

8-10 hours

More than 10 hours

How many hours of sleep do you typically get per night?

Poor sleep is linked to weight gain and increased appetite.

Less than 5 hours

5-6 hours

6-7 hours

7-8 hours

8-9 hours

More than 9 hours

Please list all your current medications (including over-the-counter and supplements)

Some medications (antipsychotics, SSRIs, insulin, steroids, beta-blockers) can cause or worsen weight gain.

What are you hoping for from this service? (select all that apply) *

GLP-1 weight loss medication (Saxenda, Wegovy, Mounjaro, etc.)

Medical assessment and blood tests

Structured weight loss programme

Help with emotional eating and behaviour change

Diet and nutrition advice

Exercise guidance and support

Exploration of bariatric surgery

Second opinion on weight loss approach

Other

What approach appeals to you most? *

Medication

Lifestyle changes (diet and exercise)

Combined medication and lifestyle changes

I'm open to advice

Is there anything else we should know about your weight loss journey?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Weight Management

What is your current weight? -

What is your height? -

What is your target weight (if you have one)? -

How long have you been trying to lose weight? -

What is your primary motivation for weight loss? -

SCOFF Eating Disorder Screen

Do you make yourself Sick because you feel uncomfortably full? -

Do you worry you have lost Control over how much you eat? -

Have you recently lost more than one stone (6.35 kg) in a 3-month period? -

Do you believe yourself to be Fat when others say you are too thin? -

Would you say that Food dominates your life? -

Eating Disorder History (if applicable)

Have you ever been diagnosed with an eating disorder? -

What is the highest weight you have been as an adult? -

What is the lowest weight you have been as an adult? -

Weight History

What was your weight at age 18 (if you remember)? -

How would you describe your weight gain pattern? -

Which weight loss methods have you tried before? (select all that apply) -

How much weight did you lose on the GLP-1 medication? -

What is the most weight you have lost through dieting? -

How quickly did you regain the weight after your diet? -

GLP-1 Safety Screening

Do you have a personal or family history of medullary thyroid carcinoma (MTC)? -

Do you have a personal or family history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)? -

Have you had pancreatitis (inflammation of the pancreas)? -

Do you have gallbladder problems or a history of gallstones? -

Do you have a history of severe stomach/gut conditions, including gastroparesis? -

If you have diabetes, do you have diabetic retinopathy (eye damage from diabetes)? -

Are you currently pregnant or planning to become pregnant? -

Do you have type 1 diabetes? -

Do you have kidney disease? -

Medical Conditions

Do you have type 2 diabetes? -

Do you have thyroid problems? -

Do you have PCOS (polycystic ovary syndrome)? -

Do you take long-term corticosteroids or have Cushing's syndrome? -

Do you have sleep apnoea? -

Do you have joint problems or arthritis affecting your ability to exercise? -

Do you have heart disease or heart failure? -

Do you have depression or anxiety? -

Do you have ADHD or take ADHD medication? -

Lifestyle

Describe your typical daily eating pattern (meals, snacks, portion sizes) -

Do you eat in response to emotions rather than physical hunger? -

Do you eat late at night after your main meal? -

How many units of alcohol do you drink per week? -

What type and how much exercise do you currently do? -

What barriers prevent you from exercising more? (select all that apply) -

How many hours per day are you typically sedentary (sitting/lying)? -

How many hours of sleep do you typically get per night? -

Current Medications

Please list all your current medications (including over-the-counter and supplements) -

Your Goals

What are you hoping for from this service? (select all that apply) -

What approach appeals to you most? -

Is there anything else we should know about your weight loss journey? -

Anything else for your doctor?