Consultation - Your Pharmacy Clinics

Weight Loss

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Question 1:Do you have any known allergies?

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Question 3:Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Question 4:Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Question 5:Do you smoke?

Question 6:Do you consume alcohol?

If yes, how much a day/weekly?

Question 7:How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Question 1:Please calculate your current BMI.

Please select either Metric or Imperial measurements :

Metric (Centimeters and Kilograms)

Imperial (Feet and Pounds)

Height

Feet

Inches

Weight

Stone

Pound

BMI Calculation:

Question 2:What are your weight loss goals? (e.g., lose a certain number of pounds/kilograms, achieve a specific BMI)

Question 3:Have you tried to lose weight before?

Question 4:What has been your experience with previous weight loss attempts? (e.g., successful, temporary weight loss, no weight loss)

Question 5:Are you currently experiencing any symptoms that may be related to your weight? (e.g., joint pain, shortness of breath, fatigue)

Question 6:Have you been diagnosed with any conditions that could affect your weight or ability to lose weight? (e.g., metabolic syndrome, hypothyroidism)

Question 7:Have you had any tests to evaluate your condition? (e.g., blood tests, metabolic tests)

Question 8:Have you been prescribed medication for weight loss before?

Question 9:Are you currently taking any medication for weight loss?

Question 10:Have you experienced any side effects from your current or past weight loss medications?

Question 11:Have you tried any non-medication treatments for weight loss? (e.g., lifestyle changes, dietary adjustments, physical therapy)

Question 12:Have you used over-the-counter treatments for weight loss?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Question 1:Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for Weight Loss.

Question 2:Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Question 3:Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Question 4:Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

Question 5:Video Consultation

Due to new regulations, we are required to have a 5-minute video call to verify your weight before we can supply weight loss treatment.

Once you place your order, we will email you to book a call with our specialist via FaceTime, WhatsApp Video, Google Meet, Microsoft Teams, or Zoom.

Please confirm that you understand and are happy to proceed with this requirement.

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

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Assessment for Weight Loss

Weight Loss

1 About Your Health

Question 1:Do you have any known allergies?

Yes

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Question 3:Are you currently taking any medications?

Yes

Question 4:Have you had any surgeries in the past year?

Yes

Question 5:Do you smoke?

Yes

Question 6:Do you consume alcohol?

Yes

Question 7:How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Question 1:Please calculate your current BMI.

Height

Weight

Height

Weight

Question 2:What are your weight loss goals? (e.g., lose a certain number of pounds/kilograms, achieve a specific BMI)

Question 3:Have you tried to lose weight before?

Yes

Question 4:What has been your experience with previous weight loss attempts? (e.g., successful, temporary weight loss, no weight loss)

Question 5:Are you currently experiencing any symptoms that may be related to your weight? (e.g., joint pain, shortness of breath, fatigue)

Yes

Question 6:Have you been diagnosed with any conditions that could affect your weight or ability to lose weight? (e.g., metabolic syndrome, hypothyroidism)

Yes

Question 7:Have you had any tests to evaluate your condition? (e.g., blood tests, metabolic tests)

Yes

Question 8:Have you been prescribed medication for weight loss before?

Yes

Question 9:Are you currently taking any medication for weight loss?

Yes

Question 10:Have you experienced any side effects from your current or past weight loss medications?

Yes

Question 11:Have you tried any non-medication treatments for weight loss? (e.g., lifestyle changes, dietary adjustments, physical therapy)

Yes

Question 12:Have you used over-the-counter treatments for weight loss?

Yes

3 The Agreement and Consent

Question 1:Understanding of Risks

Question 2:Medical Guidance

Question 3:Consent to Share Information

Question 4:Confirmation

Question 5:Video Consultation

Assessment Progress

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