Consultations Form

Lets Start…at the Start! Please fill in our consultation form as best you can and tell us a little bit about you . The more information you can provide us the better so we can customise and tailor your weight loss journey to suit you.

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Name *

Height (Feet-Inches) *

weight (Stone-pounds) (required) *

Date of Birth

Email *

Telephone number

Ethnicity (Ethnicity can affect your risk of some conditions.)WhiteAisanBlackMiddle EasternOtherPrefer not to say

conditions.) Are the

ARE YOU CURRENTLY TAKING ANY WEIGHT LOSS MEDICATION? *YesNo

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 misuseCurrent or past alcohol misuseNone of the aboveObstructive sleep apnea (OSA)Type 2 diabetes(Not taking Insulin)Polycystic ovary syndrome (PCOS)DyslipidemiaNone of the Above

Are you pregnant, planning to be pregnant, or breastfeeding?PregnantPlanning on being pregnant in the next three monthsBreastfeedingNone of the above

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
• None of the above

Date of Birth (–/–/–)

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