Q1 Weight Loss Goals

Q2 Current Weight and Height

What is your current Height *

What is your current Weight *

Q3 Comorbidities and health concerns

Do any of these apply to you? (Select all that apply.) *

Type 2 diabetes or pre-diabetes

High blood pressure (hypertension)

PCOS (polycystic ovary syndrome)

Sleep apnoea or poor sleep quality

High cholesterol or dyslipidaemia

Insulin resistance or metabolic syndrome

Joint pain related to weight (knees, hips, back)

Low energy and fatigue affecting daily life

None of these apply

Q4 What have you already tried?

Before considering a medical programme, what have you already tried? (Select all that apply.) *

Restrictive diets (keto, banting, intermittent fasting, etc.)

Gym programmes or personal training

Commercial programmes (Slender Wonder, Weigh-Less, etc.)

Pharmacy GLP-1s (Ozempic, Mounjaro, etc.) on my own

Weight loss medications (other than GLP-1s)

I've considered bariatric (weight loss) surgery

I haven't tried anything seriously yet

Q5 — Why now?

What's making you look at this right now? (Select the one that fits best.) *

My doctor told me I need to lose weight for my health

I have an upcoming event (wedding, holiday, milestone)

I'm tired of feeling unwell and lacking energy

I want to be healthier for my children or family

I've tried everything else and need real help

I'm just exploring my options for now

Q6 Contraindications and safety check

For your safety, do any of these apply? Be honest — this protects you. (Select all that apply.) *

I am currently pregnant or breastfeeding

I am trying to fall pregnant in the next 6 months

I have had pancreatitis

I have personal or family history of medullary thyroid cancer or MEN-2

I have severe gastrointestinal disease (gastroparesis, IBD flare)

I am currently being treated for an eating disorder

None of these apply

Q7 Budget readiness

Medical weight loss programmes are an investment in your health. They are not covered by SA medical aids for obesity. Which range feels comfortable for you? *

Q8 Contact details

First Name *

Last Name *

Email *

WhatsApp Nr *

Age *

Consent

I understand that I will receive my personal eligibility report by email and may be contacted by Dr Hanlie's team about my results. I understand my information is kept private and never shared.