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?

Question 1: What is your height?

Question 2 What is your current weight?(please note you will be required to provide evidence)

Question 3 What was your sex registered at birth?

Male

Female

Question 4 What is your ethnicity. (different ethnicities may have different risk factors.)

Question 6 Do you have gallbladder or bile duct issues

Yes

NO

Question 7 Do you have liver impairment

YES

NO

Question 8 Do you have diabetes?

Yes I have pre-diabetes or diet controlled diabetes

Yes and I take medication for my diabetes

NO

Question 10: Have you ever made yourself sick or vomit to control your weight?

Yes

No

Question 11: Have you ever taken laxative medicines to control your weight?

Yes

No

Question 12: Does food or image dominate your life?

Yes- both food and image

Yes- Food only

Yes- Image only

No- neither

Question 13: Do you ever eat in secret?

Yes

No

Question 14: Please list all your current medication. (Please include all items prescribed by your GP, that you buy over the counter and any herbal medicines and vitamins.)

Question 15: Please list any recreational drugs you may have taken in last 2 years

Question 16: Please list your current and previous medical conditions

Question 18: Please list any major operations you have ever had. Please list all operations in the last 6 months

Question 19: How much alcohol do you drink in an average week? (1 unit is 25ml of spirits, 2 units is 1 pint of beer, or a standard 175ml glass of wine. 3 units is 1 pint of high strength beer or a large wine,)

Question 20: Do you smoke?

No. I have never smoked

No. I quit more than 6 months ago

No. I quit less than 6 months ago

Yes. I smoke infrequently on one or two days a week

Yes. I smoke less than 10 cigarettes each day

Yes. I smoke 10 or more cigarettes each day

Question 21: How much exercise do you take each day?

Less than 60 minutes each day?

60 to 120 minutes each day?

More than 120 minutes each day?

Question 22: Please describe the types of exercise you take part in

Question 23: Are you currently using any of the following (you have had a dose within the last 2 weeks)?

Question 24: Have you ever used any of the following medicines in the past?

Question 25: Is there any further information you feel would help the pharmacist to know?

Question 26: 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 understand I should use one weight loss product at any one time

Acknowledgement 2:

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 3:

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 4:

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.

Acknowledgement 5:

I understand treatments may reduce effectiveness of oral contraceptives and that suitable precautions such as condoms should be used for 4 weeks after starting treatment and for four weeks after each dose increase. Females must stop treatment at least 8 weeks before trying to conceive.

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.