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Consultation Form
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Consultation Form
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Name
*
First
Last
Email
*
Height (Feet/Inches)
*
Weight (Stone-pounds)
*
Date of Birth
Telephone number
*
Ethnicity (Ethnicity can factor into your risk of some conditions)
*
White
Asian
Black
Middle Easter
Other
Prefer not to say
Are you currently taking any weight loss medication?
*
Yes
No
If you replied yes to the above please detail here
Do you have any of the following weight-related illnesses?
*
High Blood Pressure (Hypertension)
Heart Disease
Asthma
Chronic Obstructive Pulmonary Disease
Obstructive Sleep Apnea
Type 2 Diabetes (not taking insulin)
Polysistic Ovary Syndrome (PCOS)
Dyslipidemia
None of the Above
High Levels of one or more lipids (High cholesterol or triglycerides
Do you have or have you ever experienced any of the following?
Arrhythmia (irregular heart rhythm)
Current or past drug misuse
Current or past alcohol misuse (this one is selected in the image)
None of the above
Obstructive sleep apnea (OSA)
Type 2 diabetes (Not taking Insulin)
Polycystic ovary syndrome (PCOS)
Dyslipidemia
None of the Above
Are you pregnant, planning to be pregnant, or breastfeeding?
Yes
No
the weight pregnant,
Do you take any of the following medications?
*
Insulin
Sulfonylureas E.g. Glimepiride (Amaryl), Glipizide (Glucotrol and Glucotrol XL), Glyburide (Micronase, Glynase, Diabeta), Gliclazide, Gilbenclamide, Tolbutamide
DPP-4 inhibitors E.g. Sitagliptin, Saxagliptin, Linagliptin, Alogliptin
SGLT-2 inhibitors E.g. Empagliflozin, Dapagliflozin, Canagliflozin, Ertugliflozin
None of the Above
Do you have any of the following medical conditions?
*
Gastroparesis
Crohn’s disease or ulcerative colitis
Pancreatitis
Submit