Weight Loss Assessment Step 1 of 4 – Personal Details 0% Personal DetailsName(Required) First Last Email(Required) Phone(Required)Date of Birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email(Required) Phone(Required)Gender(Required) Male Female Are you curently pregnant, breastfeeding, or planning a pregnancy within the next 3 months?(Required)GLP-1 medications (such as Mounjaro and Wegovy) should not be used during pregnancy or while breastfeeding. If you are planning a pregnancy, you must stop using GLP-1 medication at least 3 months before. Pregnant Breastfeeding None of the above Medical QuestionsPlease ensure all information is accurate and complete to help us personalise your weight loss plan.Please select how you will measure your height(Required) Imperial (ft/lb) Metric (cm/kg) What is your height? (ft/inches)(Required)For e.g 4″3What is your weight? (st/lbs)(Required)For e.g 6st 3lbsWhat is your height? (cm)(Required)For e.g 152cmWhat is your weight? (kg)(Required)For e.g 56kgPlease tick any of the following conditions you have now or have had in the past:(Required) Pancreatitis Liver cirrhosis or a liver transplant Any form of cancer that is currently being treated by a specialist Gallstones that have not been removed, Gallbladder infection, blocked bile flow or gallbladder surgery within the last 12 months Heart failure with shortness of breath at rest Chronic kidney disease with reduced function (eGFR less than 30ml/min – you can find this information on your kidney function blood test) Severe gastrointestinal disease, including inflammatory bowel disease (eg ulcerative colitis or Crohn’s disease), or gastroparesis (delayed stomach emptying) Treatment or rehabilitation for excessive alcohol use Active retinopathy Chronic malabsorption syndrome An endocrine (hormone) disorder, such as overactive thyroid disease awaiting radioactive iodine or surgery, acromegaly, Addison’s disease, Cushing’s syndrome, congenital adrenal hyperplasia, or a growth hormone disorder Any cognitive or memory impairment, such as dementia, that may impact the ability to make decisions None of the above Unfortunately, we cannot recommend a suitable treatment for you. If you did this in error, you have the choice to change your answer. If you have any questions about this consultation, please email [email protected]. Do you have a personal or family history of medullary thyroid cancer, thyroid cancer, or multiple endocrine neoplasia type 2 (MEN2) syndrome?(Required) Yes No Please provide more informationHave you had bariatric weight-loss surgery or a gastric band procedure (either placement or removal) within the past 12 months?(Required) Yes No Have you ever had an eating disorder, for example, anorexia or bulimia nervosa?(Required) Yes No Have you tried to previously lose weight with exercise and diet alone?(Required) Yes No Please provide more information, if this has not workedAre you currently on any weight loss treatment? (Injectable or Oral)(Required) Yes No Where have you had it from? Newtons Chemist Other Upload Screenshot or Image(Required)Please upload proof (screenshot will work) of any previous treatment you have had from another supplier. Please ensure we can see your name, date of order, drug name and strength. Please note your order will be rejected if you fail to provide us with the relevant proof you already are on going treatment.Max. file size: 80 MB. Please choose which treatment you had last(Required)OrlistatWegovyMounjaroSaxendaWhat is your target weight in kg?(Required)Are you requesting more than one pen today?(Required) Yes No Please provide more information(Required)Please measure your waist circumference in cm. This is the area just above your belly button, all the way around your waist.(Required)Do you suffer from any of the following weight related conditions?(Required) Type 2 Diabetes Prediabetes Obstructive Sleep Apnoea High Cholesterol High Blood Pressure Heart Disease Previous Stroke None of the above If you have type 2 diabetes, are you using insulin?(Required)If yes, it’s important to let us know here. This treatment can affect insulin requirement and blood sugar regulation, so GLP-1 medication should only be prescribed to people with type 2 diabetes using insulin under the supervision of a diabetes team. Yes No If you have type 2 diabetes, are you taking any oral or injectable medication (other than metformin and insulin) to manage your blood sugar?(Required) Yes No Are you currently taking any of the following medications?(Required) Acarbose (an anti-diabetic drug used to treat Type 2 Diabetes Mellitus Anti-epileptics Anti-depressants Amiodarone Carbamazepine Ciclosporin Clozapine Digoxin Fenfluramine HIV medication Iodine Salts Lithium Mycophenolate mofetil Oral anticoagulants such as Warfarin Oral methotrexate Phenobarbital Phenytoin Somatrogon Tacrolimus Theophylline Thyroid medication Warfarin Yes No Please state which medication:(Required)What is your blood pressure?Low (below 90/60mmHg)Normal (90/60mmHg to 140/90mmHg)High (over 140/90mmHg)Not sureDo you have any allergies or hypersensitivity to the medication you are requesting?(Required) Yes No Please specify your allergies.(Required)Please tell us about any other medicines you take (if any)?Leave this blank if you do not take any other medicines.How long have you taken Alli or Orlos (Orlistat)?(Required) This will be the first time Less than 6 months 6 months or more Please confirm how many calories you have on a daily basis?(Required)Less than 2,000 calories a dayBetween 2,000 to 2,500 calories a dayMore than 2,500 calories a dayHow much exercise do you do each week?(Required)No exercise1 hour1-2 hoursMore than 2 hours Video Verification Please upload a short video of yourself stating today’s date and your current weight. This is required by law to confirm your details.If you are on a mobile phone, please upload a short video stating today’s date and your weight. If you are on a desktop, you can complete this step later from your phone.Please upload a short video of yourself stating today’s date and your current weight.To confirm your current weight, please submit a short video. Ensure your full torso is visible. Record yourself facing the camera for 3–5 seconds, then turn to a side profile for 3–5 seconds. Please state the date and your current weight clearly in the video.Max. file size: 80 MB. What is your ethnic background?(Required)Choose all that apply. We ask this healthy weight ranges differ for different ethnic backgrounds. White (including White British, White Irish, and other backgrounds) Asian or Asian British (including the Indian subcontinent) Black, African, Caribbean, or Black British Middle Eastern or Middle Eastern British Latino or Hispanic or Latino/Hispanic British Mixed or multiple ethnic backgrounds Other ethnic group Prefer not to say AgreementBy providing your consent, you acknowledge that you understand and agree to the treatment plan and associated terms below.If you are sexually active,(Required)Note that Mounjaro may reduce the effectiveness of the oral contraceptive pill. This means you’ll need to use other forms of contraception (such as condoms or an IUD/implant) while taking Mounjaro to prevent unplanned pregnancy. Do you agree? Yes No Do you agree that you will keep the pen in a refrigerator (between 2°C to 8°C) once you receive your delivery. If you do not do this, Newtons Chemist cannot and will not be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C. This medicine can only be delivered via Royal Mail Special Delivery Guaranteed by 1pm due to it being a fridge item. This delivery service is exempt from any free delivery offers or promotions.Confirmation(Required) I confirm the above Do you agree that you will keep the pen in a refrigerator (between 2°C to 8°C) once you receive your delivery. If you do not do this, Newtons Chemist cannot and will not be held responsible for the medication not functioning as intended. Once you start using the pen, you can keep the pen for 1 month when stored at a temperature below 30°C. Do you confirm that if you have not ever had any weight loss medication, you are required to start on the lowest strength. Choosing a higher strength will result in an automatic rejection of your order. A higher strength can only be selected if you have ongoing treatment from us or elsewhere providing there is evidence of treatment.Confirmation(Required) I confirm the above Do you accept that all orders placed for weight loss medication from Friday 2pm onwards, Saturday and Sunday will be shipped out on Monday due to the items being temperature controlled. Please ensure you are able to receive your delivery as Newtons Chemist will not be liable for any missed deliveries.Confirmation(Required) I confirm the above Please confirm that you understand the importance of drinking at least 2–3 litres of water each day during this treatment, as not doing so may lead to dehydration and other health issues.Confirmation(Required) I confirm the above In order to continue this treatment, you are required a 5% weight loss over 3 months from starting treatmentConfirmation(Required) I confirm the above Please note that if your BMI drops below a safe level, Newtons Chemist practitioners will need to adjust or stop your treatment to protect your health.Confirmation(Required) I confirm the above Please confirm that any treatment should be taken with a nutritionally balanced diet with exercise. This is a calorie controlled diet, of which around 30% of the calories come from fat.Confirmation(Required) I confirm the above I confirm that I am 18 years of age or older. I agree to attend follow-up consultations with Newtons Chemist practitioners to ensure this treatment remains suitable for me. I confirm the medicine requested is for my personal use only. I will read the patient information leaflet provided with the medicine, paying particular attention to the dosage instructions and possible side effects. I take responsibility for informing my regular doctor about this online consultation and any changes to my health circumstances. I confirm that all answers I have provided are truthful and accurate. I understand that my request will be reviewed by a prescriber, and approval is not guaranteed until they confirm suitability. I confirm that I have the capacity to make my own healthcare decisions. I agree to Newtons Chemist terms and conditions. I understand that prescribers rely on the information I provide to make safe and appropriate prescribing decisions, and that providing false or misleading information could put my health at risk.Confirmation(Required) I confirm the above It’s essential for your GP to know about all the medications you are taking to ensure you receive the best possible care. Sharing this information helps maintain a complete medical record, including medications prescribed from all sources, hence in order to proceed for Weight Loss treatment we will need your GP details.Confirmation(Required) I am happy for Newtons Chemist to contact my GP regarding this consultation Please check you understand and agree to this treatment information: • I understand that rapid weight loss and injectable weight loss treatments like Mounjaro, Wegovy and Nevolat can raise the risk of pancreatitis and gallbladder issues. If I have severe abdominal pain, vomiting, jaundice (yellowing of the skin), or worsening symptoms, I will seek urgent medical help. • I understand that severe diarrhoea for over 24 hours, or vomiting within 3 hours of taking the contraceptive pill, can reduce its effectiveness. If this happens, I will call my GP or 111 for advice. I understand I may need a repeat dose of the contraceptive pill or to use additional contraception. • I understand that rapid weight loss and injectable weight loss treatments like Mounjaro, Wegovy and Nevolat should not be combined with other weight loss medications. • I recognise that these treatments may affect my mood. If I experience low mood or any mental health issues, I will stop the treatment and consult a doctor immediately. I confirm that I understand and agree to the above.Practice Name(Required)Practice Address(Required) Street Address Address Line 2 City Postcode Practice Phone Number(Required)Consent(Required) I confirm the details are true and I consent to processing my health data.Please confirm you agree the following:(Required)Do you consent to us requesting further information on your medical history from your GP? This is to ensure that any treatment we recommend for you is appropriate and safe. For full details, please click the “Need help?” link below. Any references to “we” or “us” refers to ABSM Healthcare Limited. I confirm the aboveConsent(Required) Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP? One or more of your answers means this online service is not suitable for you. You will not be able to complete this form. Please contact your GP or another healthcare professional.
