ROBERT HOWELL Your Smile Clinic – Wegovy and Mounjaro Training

Step 1 of 6 - About you

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Clinic Name

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Clinic Postcode

1) About You

1.1) Name*

First name Surname

1.2) Address*

House number or name City Postcode

1.3) Phone number*

1.4) Email Address*

1.5) Date of birth*

DD slash MM slash YYYY

1.5.1) Age*

You must be aged between 18 - 75 to use our service. If you need to speak to a healthcare professional about treatment, please arrange to see your GP.

1.6) Gender*

Female

Male

1.6.1) Are you pregnant, breastfeeding or trying to get pregnant?*

Yes

This treatment is not suitable if you are pregnant, trying to get pregnant or breastfeeding. We recommend you speak to your GP in person.

1.7) Height*

1.7) Weight*

ST/LBS

LBS

1.8) Height*

FT/IN

1.9) BMI*

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Weight & Height

Imperial

Metric

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Feet

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Inches

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Metres

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Centimetres

1.8) Weight*

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Stones

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Pounds

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Kilograms

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1.9) BMI

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Hidden weight kg

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Hidden height cm

1.10) What is your usual blood pressure range?*

2) About your Health

Please be aware that it is important to give truthful information about your medical history.

2.1) Do you suffer from any heart problems?*

For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.

Yes

Please give details*

2.2) Do you have any thyroid problems?*

For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.

Yes

Please give details*

Losing weight and keeping it off can be a struggle, especially if you have an under-active thyroid. Please ensure you have regular bloods taken with your GP to ensure you are taking the correct dose of thyroxine.

2.3) Have you, or anyone in your immediate family ever had thyroid cancer?*

Yes

Please give details*

2.4) Do you currently, or have you ever had pancreatitis?*

Yes

Please give details*

2.5) Do you suffer from any kidney problems?*

Yes

Please give details*

2.6) Do you suffer from any liver problems?*

For example: hepatitis, fatty liver, alcohol liver disease etc.

Yes

Please give details*

2.7) Do you suffer from any SEVERE gastro-intestinal problems?*

For example: inflammatory bowel disease or gastroparesis etc

Yes

Please give details*

2.8) Do you suffer with diabetes?*

Yes

2.8.1) Are you taking Insulin?*

Yes

Please give details*

2.9) Do you suffer from any mental health problems?*

For example: severe anxiety, severe depression, schizophrenia, personality disorders, body dysmorphia, thoughts of suicide etc.

Yes

Please give details*

2.10) Do you suffer with an eating disorder?*

For example: anorexia, bulimia, binge eating etc.

Yes

Please give details*

2.11) Do you have any other medical problems?*

Yes

Please give details*

2.12) Are you taking any other medication not already identified above?*

For example other prescribed medication, products purchased over-the-counter or herbal supplements

Yes

Please list all medicines and what they treat.*

2.13) Do you have any known allergies?*

Yes

Please list your allergies*

2.14) It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'YES' below to give us your permission to do so.*

Yes

GP name

GP practice address

GP practice telephone number

GP practice email address

3) About your lifestyle

3.1) Do you smoke?*

Yes

How many per day?*

3.2) Do you drink alcohol?*

Yes

3.2.1) How many units per week? Copy and paste this link to calculate your units https://www.drinkaware.co.uk/sevendaycalculator*

Excessive alcohol consumption can increase the risk of serious health issues. To get help with cutting down drinking, visit this page.

3.3) How many cups of tea or coffee do you drink each day?*

3.4) How many glasses of water do you drink each day?*

NB. It is very important to stay hydrated when taking this medication in order to reduce potential constipation

3.5) How many hours of sleep do you average each night?*

Lack of sleep can affect two important hunger hormones, (ghrelin and leptin) making you feel hungry and increasing your appetite.

3.6) How much exercise / activity do you do each week?*

NB. This doesn't have to be set time in the gym, it can be ANY activity that gets your heart pumping. (Current guidelines recommend 150 minutes of moderate aerobic activity or 75 minutes vigorous activity per week)

4) Your weight-loss journey

4.1) How many calories do you consume per day?*

4.2) Please describe your typically daily diet*

4.3) What contributes to your excess weight? (Please tick ALL that apply)*

Large portion sizes

Emotional eating

Compulsive eating

Reward eating

Waking and eating at night

Eating out / Takeaways

Medication

Yo-Yo dieting

Snacking between meals

Lack of exercise

Lack of will power

Lack of motivation

Limited mobility

Other

4.4) Please tell us what weight loss interventions you have previously tried*

For example: weight watchers, slimming world, increased exercise, went to see GP, medication etc

4.5) Are you currently taking any weight loss treatments such as Mysimba, Saxenda, Wegovy, Ozempic or Phentermine?*

Yes

Which one, and how long have you been taking it?*

5) Declaration & Consent to Treatment

5.1) Kindly TICK to confirm that you agree with each of the following statements if you wish to proceed with treatment, then please sign your name below

I have answered all questions truthfully, and I am aware that It is a criminal offense to give false or misleading information about my health

I am over the age of 18

This prescription request is for my own personal use

I will read the patient information leaflet supplied

I agree to follow the dosing schedule prescribed

I am aware that I must combine treatment with a reduced calorie diet and increased physical activity for best results

I agree to record my daily food intake and physical activity

I am aware that there are no guarantees of weight loss using any of these treatments

I understand that if I have not lost 5% of my initial body weight after 12 weeks of being on the licensed dose, I must discontinue treatment

I wish to commence the Programme if I am found to be a suitable candidate following my consultation, and I consent to treatment

Should I experience any changes in my medical history, I will immediately inform the clinic

Patient Signature*

5.2) How did you locate the consultation form?*

Website link

Facebook link

Instagram link

Link in an email we sent

Link in a message we sent

Through a friend

Other

Please specify*

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Date*

DD slash MM slash YYYY

6) Readiness to change

This questionnaire is designed to help you and your practitioner decide if this is a good time in your life for you to begin a weight management Programme. Just be as honest with yourself and select the answers you feel most apply to you.

6.1) Do you feel motivated to lose weight at this time?*

0 : Not at all motivated

1 : Slightly motivated

2 : Somewhat motivated

3 : Quite motivated

4 : Extremely motivated

6.2) How motivated are you to change your eating habits at this time?*

0 : Not at all motivated

1 : Slightly motivated

2 : Somewhat motivated

3 : Quite motivated

4 : Extremely motivated

6.3) How motivated are you to increase your physical activity at this time?*

0 : Not at all motivated

1 : Slightly motivated

2 : Somewhat motivated

3 : Quite motivated

4 : Extremely motivated

6.4) How motivated are you to try new strategies/techniques for changing your dietary, physical activity and other health related behaviors at this time?*

0 : Not at all motivated

1 : Slightly motivated

2 : Somewhat motivated

3 : Quite motivated

4 : Extremely motivated

6.5) People who want to achieve long-term weight control need to spend time every day trying to plan for healthy meals, physical activity and behavior change. How confident are you that you can devote time and effort, now and over the next few months?*

0 : Not at all confident

1 : Slightly confident

2 : Somewhat confident

3 : Quite confident

4 : Extremely confident

6.6) How confident are you that you will be able to record everything you eat and drink and your activity each day for 2-4 weeks?*

0 : Not at all confident

1 : Slightly confident

2 : Somewhat confident

3 : Quite confident

4 : Extremely confident

6.7) How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?*

0 : Not at all satisfied

1 : Slightly satisfied

2 : Somewhat satisfied

3 : Quite satisfied

4 : Extremely satisfied

Name

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