weight loss enquiry form | Highland Pharmacy

Preferred pharmacy

First name

Last name

Birthday

Day

Month

Year

Phone Number

Email

Address

I agree that the pharmacist may contact my GP practice to confirm my medical history to ensure that it is suitable for me to receive weight loss treatment. (Note agreement for gp contact is a condition for supply.)

GP Name, address and contact number/ email

Is there an ideal time or day to arrange a consultation or times to avoid?

What would you prefer

I would be most interested in the following product

Do you have or had any of the following conditions

What is your height?

What is your current weight?(please note you will be required to provide evidence)

What is your main goals for losing weight? and do you have a target weight in mind?

Please list your current and previous medical conditions. All recent and any major operations. Please either list of all your current medications- You can attach a photo of all your repeat medications below

You can attach a photo or a list of repeat medications here

Conditions associated with weight

Is there a family history- in parents or siblings with any of the following?

Question 8: Alcohol and smoking

What was your sex registered at birth?

Male

Female

What is your ethnicity. (different ethnicities may have different risk factors.)

Please enter a recent blood pressure measurement if known

Please record your average resting heart rate if known

Do you have gallbladder or bile duct issues

Yes

NO

Please list any recreational drugs you may have taken in last 2 years

Do you have any allergies?

Are you currently using any of the following (you have had a dose within the last 2 weeks)?

Have you ever used any of the following medicines in the past?

Is there any further information you feel would help the pharmacist to know?

We are required to visually check you weight against your BMI.

I will collect medicines from the pharmacy and agree the pharmacy staff can check my height and weight.

I will have my medicines delivered and agree to upload photos using the photo evidence form. ( You do not need to do this yet- only once a treatment plan is agreed!)

Acknowledgement 1:

I agree the pharmacy staff can check my height and weight and nwhere appropriate phot evidence may be asked to be uploaded using the photo evidence form.

Acknowledgement 2:

I understand I should use one weight loss product at any one time

Acknowledgement 3:

I understand the safest and most effective weight loss outcomes are achieved by slowly increasing dose to gain the maximum benefit from the lowest dose possible. I understand that if I have a gap in treatment longer than 2 weeks, I may need to reduce my dose to avoid side effects.

Acknowledgement 4:

I understand that Wegovy/Mounjaro is an under the skin injection. I will not inject it into a vein or muscle. The best places to give the injection are the upper arms, stomach or upper legs. I will ensure to drink plenty of fluids to avoid dehydration. Detailed instructions will be found in the patient leaflet.

Acknowledgement 5:

I understand that I will stop treatment and inform the pharmacy and/or seek medical attention if I experience severe dehydration, e.g. dark urine, confusion, blood in stool or vomit, diarrhoea lasting longer than 72 hours, or being unable to keep food down without vomiting/diarrhoea.

Acknowledgment 6:

I understand that if I experience any side effects from treatments, I can contact the pharmacy Pharmacy, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient Information Leaflet

Acknowledment 7:

I confirm that all the above information is truthful and accurate. I agree to inform the pharmacy of any changes to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed.

Side effect 1:

Aspiration during anesthesia. Patients MUST inform health teams and anesthetists they are taking a glp-1 and or GIP agonist

Side effect 2:

Contraception. For month one after initiation and dose changes, females of a reproductive age, need to use barrier method in addition to oral contraception

Side effect 3:

Low blood sugar. Your risk for getting low blood sugar may be higher if you use a GLP1 with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin.

Side effect 4:

Dehydration. Diarrhoea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems. It is important for you to drink fluids to help reduce your chance of dehydration.

Side effect 5:

Stomach problems. Stomach problems, sometimes severe, have been reported in people. Tell your healthcare provider if you have stomach problems that are severe or will not go away.

Side effect 6:

Changes in vision.Tell your healthcare provider if you have changes in vision during treatment

Side effect 7:

Gallbladder problems. pain in your upper stomach (abdomen), fever, yellowing of skin or eyes (jaundice), clay-coloured stools

Side effect 8:

Most common side effects nausea

diarrhoea
decreased appetite
vomiting
constipation
indigestion
stomach (abdominal) pain

Side effect 9:

Inflammation of your pancreas (pancreatitis):

Stop using immediately and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back