Weightloss consulatations - Chemist2Customer

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HomeWeightloss consulatations

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Your Details
Consultation
LifeStyle
Personal Info
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Personal Info

Name

Email

Phone

WeightLoss

Height (cm)

Weight (kg)

Consultation

What are your primary reasons for wanting to lose weight?

I am worried about obesity

My weight affects my personal life

My weight affects my health

Feeling sad or depressed

Lack of energy or motivation

Diet and exercise haven’t resulted in any weight loss

Need to lose weight for an event (social event, surgery)

Other (please explain)

LifeStyle

We would like to know about your lifestyle

I smoke occasionally

I smoke regularly

I drink alcohol occasionally

I drink alcohol regularly

I eat takeaway/fast food a few times a week

I eat takeaway/fast food on most days of the week

I eat snacks, crisps, cakes, chocolates, biscuits, or other food that are high in saturated fats a few times a week

I eat snacks, crisps, cakes, chocolates, biscuits, or other food that are high in saturated fats most days of the week

I do 150 minutes or more of moderate intensity exercise each week – any activity which gets you out of breath I.e. brisk walking, riding a bike, water aerobics

I do 75 minutes or more of vigorous intensity exercise each week – any activity inwhichyou are not able to say more than one or two words I.e. running, swimming fast, sports, skipping rope.

In order to track you progress in weight management, please upload a photo of yourself.

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Information

Have you already tried to lose weight by eating healthily and exercising regularly?

Yes No

Are you pregnant or breastfeeding?

Yes No

Are you pregnant or breastfeeding?

Normal kidney function Impaired/reduced kidney function Never tested

Have you ever been diagnosed with liver disease?

Yes No

Are you taking oral contraception? Some weight loss treatments cause nausea or diarrhoea. Please follow the missed pill rules for your contraceptive if you experience significant symptoms. It may be advisable to use a barrier method of contraception as well as your pill whilst using weight loss medications. Advice on missed pills can be found here. Treatment with GLP1 type medication (Saxenda, Wegovy, Mounjaro, Ozempic) whilst pregnant may harm an unborn baby. Please ensure that you use adequate contraception whilst using GLP1s. Please contact your GP if you become pregnant whilst using these medications.

Yes No

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