contact@gmail.com

Open: Mon – Sat, 9:00 AM – 6:00 PM (GMT)

Home
About
Screening
Medications
FAQ
Contact

Home
About
Screening
Medications
FAQ
Contact

Book an Appointment

Your First Step Towards Better Health

Answer a few simple questions to help us understand your health needs.

Weight Management | Risk Assessment Form

Date:

Patient's personal details

Title

Mr Miss Ms: Mrs: Dr:

First Name :

Last Name:

Telephone:

D.O.B:

Age :

Gender

Patient Address:

GP Name and Address:

Would you like us to send a copy of this consultation to your GP?

Yes

Patient's personal details :
Tick which of the following applies to you…

Do you have any recent or past medical history of note?

Yes No

Have you had a serious reaction to orlistat before?

Yes No

Have you received advice from a weight management counsellor before?

Yes No

Are you on any medicines? Including other anti-obesity drugs? Or ciclosporin, acarbose, oral anticoagulants, levothyroxine, oral contraceptives, fat-soluble vitamins, amiodarone or any anti-epileptic drugs?

Yes No

Do you have a medical history of any of the following: chronic malabsorption syndrome, cholestasis, hepatic or renal dysfunction?

Yes No

Current Health :
Tick which of the following applies to you...

Would you object to a low calorie diet as part of treatment?

Yes No

Has a low-calorie diet failed to manage your weight in the past?

Yes No

Body Mass Index – weight in kg divided by the square of patients height
Tick which of the following applies to you...

Is your body mass index (BMI) greater or equal to 30 kg/m²?

Yes No

Is your body mass index (BMI) greater or equal to 30 kg/m²?

Yes No

Do you suffer from diabetes, coronary heart disease, hypertension, sleep apnoea or hypercholesterolaemia? If so, is your BMI above 28 kg/m²?

Yes No

WOMEN ONLY
Tick which of the following applies to you...

Are you pregnant or planning a pregnancy?

Yes No

Are you breastfeeding?

Yes No

Write below any further information which may be relevant

e.g. medicines taking, conditions, concerns...

Screening

Why These Questions Matter

This quick screening helps us personalize your consultation. By sharing your health details, our clinician can better guide you with the right care plan.

What Happens Next?

After submitting your answers, our clinician will review your information. You’ll then be able to book an appointment for a personalized consultation.

Why Choose Me ?

Personalized, one-to-one care .
Holistic approach: nutrition, lifestyle, and medical expertise.
Flexible appointments: online & in-person.
Focus on safe, effective, and sustainable results.

Personalized Care That Brings Real Transformation.

Thinking about managing your weight? Get expert guidance now with a specialist consultation.

Book an Appointment

Personalized Care That Brings Real Transformation.

Thinking about managing your weight? Get expert guidance now with a specialist consultation.

Book an Appointment

GPhC registration number

2059552

Schedule a consultation today and let our experts guide you every step of the way.

Quick Links

About
Book an appointment
Medications
FAQ
Contact

Get in Touch

Book an Appointment
Health Screening
Send Your Query

Clinic Hours

Mon – Fri: 9:00 AM – 5:00 PM
Sat – Sun: Closed