Thank you for your interest in Aeternum's Virtual Weight Management Programme.

This assessment allows our prescribing team to determine whether prescription weight loss medication may be suitable for you.

Completing this form does not guarantee that treatment will be prescribed.

All responses will be reviewed by an independent prescriber who may request additional information or arrange a consultation before making a prescribing decision.

Our Virtual Weight Management Programme is designed to support your long-term health, not simply prescribe medication.

We take the time to ensure treatment is safe, appropriate and tailored to your individual needs. This assessment is the first step in that process.

Section 1 - About You

Country

Are you completing this form yourself?

Yes

If No, who is helping you? What is your relationship? Why do you require assistance?

Do you have any accessibility requirements or communication needs?

Section 2 - Identity Verification

To help us comply with current prescribing regulations, please upload one of the following:

• Passport

• Driving Licence

Upload your passport or driving licence here:

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

GP Address including Postcode:

We routinely notify your GP when prescription weight loss medication is prescribed as part of safe clinical practice. Would you prefer that we do not inform your GP?

Yes

If yes, please tell us why? (This request will be reviewed by your prescriber before treatment proceeds.)

Section 4 - Your Weight Loss Journey

What would you most like to achieve over the next six months?

Which of the following best describes your goals?

Have you tried to lose weight through diet and lifestyle changes for at least three months?

Yes

Have you previously used prescription weight loss medication?

Please tell us about your experience.

Already taking weight loss medication?

If you are currently receiving prescription weight loss medication from another provider and wish to continue your treatment without restarting at the lowest dose, you will need to upload a copy of your most recent prescription or dispensing label. This must clearly show your name, the medication, strength and date of issue, and must have been issued within the last 4 weeks. Without this evidence, our clinicians may be unable to continue treatment at your current dose and may recommend starting at a lower dose or request further assessment.

Please upload your latest prescription here:

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

What is your weight loss goal?

Which treatment are you interested in?

Section 5 - Current Measurements

Have these measurements been taken within the last seven days?

Yes

What is the highest weight you have been as an adult?

Approximately how long have you struggled with your weight?

Section 6 - Lifestyle

Which best describes your activity level?

Yes (please tell us which medicines)

Which best describes your eating habits?

Do you smoke or vape?

Never

Former Smoker

Current Smoker

Vape only

How many units of alcohol do you drink each week?

Section 7 - Medical History

Have you ever been diagnosed with any of the following?

If any of the above are selected, please provide details:

Have you had your blood pressure checked within the last 12 months?

Yes

If yes, please enter your reading if known.

Section 8 - Mental Health

Have you ever been diagnosed with:

If yes, please provide details:

Do you currently feel under pressure from anyone to lose weight?

Yes

If yes, please explain:

Are you choosing to start treatment of your own free will?

Yes

Unsure

Section 9 - Women's Health

Are you:

Pregnant

Trying to conceive

Breastfeeding

None

Are you taking the oral contraceptive pill?

IF YES, IMPORTANT: If Mounjaro is prescribed, it may reduce the effectiveness of the oral contraceptive pill during treatment initiation and after each dose increase. Additional contraception may be required. Your prescriber will discuss this with you if appropriate.

Section 10 - Medication & Allergies

Please list all medications you currently take.

Please list any vitamins or supplements you currently take.

Do you have any medication allergies?

If yes, please provide details.

Section 11 - Family History

Has anyone in your immediate family been diagnosed with:

Section 12 - Additional Information

Is there anything else you feel your clinician should know?

I confirm that:

The information I have provided is accurate and complete to the best of my knowledge.

I understand that deliberately providing false or misleading information may result in treatment being refused or discontinued.

I understand that completing this form does not guarantee that treatment will be prescribed.

I understand that an independent prescriber may contact me for additional information before making a prescribing decision.

I understand that further identity verification may be required before medication can be supplied.

I understand that, if appropriate, I will be asked to complete medication-specific consent forms before treatment begins.

I understand that, my details and prescription will be shared with our pharmacy partner so that they can arrange dispensing and delivery of the medication, through UK registered pharmacies.

Submit Assessment

Thank you for completing your Initial Clinical Assessment. Please sign below and submit for review.

Our prescribing team will carefully review your information.

If we require any additional information, we will contact you.

If you are clinically suitable to proceed, we'll guide you through the next stage of your assessment and treatment journey.

Please sign here:

Clear