Medical Weight Loss Assessment

Please complete this form in as much detail as possible. It will form the basis of your treatment plan.

Upon submission, our Medical Team will review and make contact as soon as possible.

First Name *

Last Name *

Phone *

Email *

Date of birth *

Your Aims:

Think about yourself in 6 months time; what would you like to have achieved by then with Team Aeternum’s support? Hint: whilst this might be weight loss; also have a think about what other areas you would like to see change e.g. health aspects, daily function, mood, confidence:

Medical History:

What is your height?

What is your weight?

What is your waist circumference?

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

Yes

What is your usual blood pressure range? (Please select from the list)

Are you pregnant, trying to get pregnant or breast feeding?

Yes

Do you have a known allergy to any of the following*:

* Multiple options may be selected.

Have you or anyone in your family ever had cancer of the thyroid or adrenal gland?

Yes

Do you have a history of heart problems? (eg abnormal heart rhythms, heart disease, past heart attack, heart failure)

Yes

Do you have an inflamed bladder or gallstones?

Yes

Do you suffer from any SEVERE gastro-intestinal problems? (eg, inflammatorybowel disease, gastroparesis, etc)

Yes

Do you have a history of pancreatitis?

Yes

Do you have severe renal (kidney) disease or impairment?

Yes

Do you have any disorders of the liver? (eg, hepatitis, fatty liver, alcohol liver disease, etc)

Yes

Do you have any disorders of the thyroid? (eg. Goiter, Graves Disease, Hypothyroid, Hyperthyroid, etc)

Yes

Do you have any form of Diabetes?

Yes

Have you ever had any major surgery?

Yes

Do you have any mental health problems? (eg, Schizophrenia, Personality Disorder, thoughts of self-harm, etc)

Yes

Have you ever been diagnosed with an eating disorder? (eg, anorexia, bulimia, binge eating, etc)

Yes

Are you taking any other medications (prescribed, over the counter and/or herbal)?

Yes

Is there anything else in relation to your general health that you wish to disclose, that may be relevant to your treatment?

In general, how healthy do you feel today? Choose a number from 0 to 100. 0 being the worst health you can imagine and 100 being the absolute best.

Lifestyle:

Answering these questions will help us tailor our support alongside your medication regimen to help ensure you stay well and get the best results.

Do you follow a particular dietary pattern e.g. vegetarian / vegan? If yes please explain below:

How many main meals do you eat daily?

0 to 1

1 to 2

2 to 3

More than 3

How many glasses of fluid do you have each day? (you can include water, squash, tea, coffee and diet soft drinks in this count)

How many portions of fruit and vegetables do you have each day? (one portion = one handful)

How many days out of 7 would you include a food that is higher in fat or sugar? E.g. chocolate / cake / biscuits / crisps.

How many days out of 7 would you have takeaway or eat out?

How many days out of 7 would you drink alcohol?

How many days in the last week have you walked more than 10 minutes?

How many times in the last week have you completed any moderate activity that lasts longer than 10 minutes? (any form of movement that got your heart beating faster and feeling out of breath)

How much time do you tend to spend sitting on a typical weekday? (hours and minutes)

Have you ever been told you have low levels of a particular vitamin/ mineral in your blood e.g. vitamin D or iron deficiency? If yes please explain below:

Do you take any regular vitamin or mineral supplements? If yes please explain below:

What have you already tried to do to lose weight?*

*Choose all that are relevant.

Have you used any Weight Loss Medications previously?*

*Choose all that are relevant.

Are you currently taking any OTHER weight loss medications? (eg. Orlistat, Xenial, Alli, Mysimba, Phentermine, etc)

Declaration and Consent:

If you wish to proceed with treatment, please tick the check boxes to confirm that you agree with each of the following statements.

Please tick to confirm:

I am over the age of 18 years.

The prescription request is for my own personal use.

I have answered all of the questions truthfully, and I acknowledge that incorrect information can be dangerous to my health.

I understand that you take my answers in good faith and that you base your prescribing decisions accordingly.

I will inform my GP of this treatment.

I will read the patient information supplied with any medication prescribed.

I understand that I must combine any prescribed treatment with a reduced calorie diet and increased physical activity for best results.

I understand that there is no guarantee with regards weight loss achievable and that weight loss is individual to each person and their circumstances.

I agree to your terms and conditions and give my consent to treatment, if I am found to be suitable.

Please sign here:

Clear