Quiz

Full Name

Date of Birth(You cannot proceed if you are under 18)

Units

kg / cmlbs / ft-in

What is your current weight (kg)?

What is your height (cm)?(We will calculate your Body Mass Index [BMI])

What is your current weight (lbs)?

What is your height?

Feet

Inches

(We will calculate your Body Mass Index [BMI])

Your weight loss journey so far...
How long have you been trying to lose weight?

Less than a year1 - 3 yearsMore than 3 years

Tell us more...

Please tell us more about what you have tried in the past to lose weight:

First, a bit about you... What are your main reasons for wanting to lose weight?

You can select multiple answers.

To improve my physical healthTo support my mental wellbeingTo manage or improve a health conditionTo improve my chances of getting pregnant in the futureTo feel more comfortable and confident in my bodyOther

Have you ever been diagnosed with, or are you currently being investigated for anxiety, depression, or any other mental health condition?

YesNo

What have you tried already?

What have you tried in the past to lose weight? You can select multiple answers.

DietingMeal replacements and shakesExerciseWeight loss apps or trackersWeightWatchers or similar programmesNone of the aboveOther

What is your ethnicity

WhiteArab or Middle EasternAsian - ChineseAsian - South AsianAsian - Any OtherBlack - CaribbeanBlack - AfricanBlack - Any OtherMixed - White & Black CaribbeanMixed - White & Black AfricanMixed - White & AsianMixed - White & Arab or Middle EasternMixed - Any OtherOther

What is your gender?

MaleFemaleTransgenderNon-binaryOther

Have you been diagnosed with any of the following?

Type 2 diabetesObesity (BMI ≥ 30)PrediabetesNone of the above

Have you ever been diagnosed with any of the following conditions?

Type 1 diabetesHistory of pancreatitisSevere kidney diseaseSevere liver diseaseGallbladder problemNone of the above

Have you ever been diagnosed with a thyroid condition?

Hypothyroidism (underactive thyroid)Hyperthyroidism (overactive thyroid)Nodules, goiter, or thyroid enlargementMedullary thyroid carcinoma (MTC), or family history of MTCMultiple Endocrine Neoplasia syndrome type 2 (MEN2)None of the above

Are you currently taking any of the following medications?

Insulin - Internal (May need physician review)

If yes, which one and when was the first dose and last dose?

Other GLP-1 receptor agonists (e.g., Ozempic, Wegovy)None of the above

Are you currently pregnant, breastfeeding, or planning pregnancy in the next 6 months?

YesNoNot applicable

Lifestyle and Goals

What is your primary goal with this program?

Blood sugar managementWeight lossBothOther

Are you allergic to any of the following?

Tirzepatide (active ingredient)

Sodium phosphate dibasic heptahydrate

Sodium chloride

Glycerin

Phenol

Hydrochloric acid (pH adjuster)

Sodium hydroxide (pH adjuster)

Water for injection

YesNo

Do you have any other allergies you haven't already told us about?

YesNo

Would you like us to inform your GP when you start prescription medication for weight management?

We recommend this to help avoid any interactions with other medications they may prescribe for you.

YesNo

If yes, please provide your GP's details:

GP Name

GP Practice Address

GP Practice Phone Number

Confirmation

You understand that a clinician will review this consultation form to determine if this medication is suitable for you before prescribing.

You agree to us sharing your details and responses from this consultation form with our partner The O’pen Wellness so that their clinicians can conduct a clinical assessment and prescribe the medication.

You agree to The Open Wellness sharing your details and prescription with Pharmaease so that they can dispense and deliver the medication.

You consent to the clinicians and pharmacy reviewing your NHS Summary Care Record (SCR) in order to confirm that the medication is suitable for you.

You are requesting this treatment only for yourself.

You will read the Patient Information Leaflet that is supplied with the medication.

You have answered all the questions accurately and truthfully so that the clinician can make appropriate decisions that are safe for you. You understand that incorrect or false information may put your health at risk.

You will let us or the clinicians know if anything you have told us in this consultation changes, especially if you start taking any new medication or get diagnosed with any new medical conditions.

You confirm you have read and agree with all of the statements above.

Your weight loss journey so far... How long have you been trying to lose weight?

Tell us more...

First, a bit about you... What are your main reasons for wanting to lose weight?

Have you ever been diagnosed with, or are you currently being investigated for anxiety, depression, or any other mental health condition?

What have you tried already?

What is your ethnicity

What is your gender?

Have you been diagnosed with any of the following?

Have you ever been diagnosed with any of the following conditions?

Have you ever been diagnosed with a thyroid condition?

Are you currently taking any of the following medications?

Are you currently pregnant, breastfeeding, or planning pregnancy in the next 6 months?

Lifestyle and Goals

What is your primary goal with this program?

Are you allergic to any of the following?

Do you have any other allergies you haven't already told us about?

Would you like us to inform your GP when you start prescription medication for weight management?

Confirmation

Previous GLP-1 Medication Review

Your weight loss journey so far...
How long have you been trying to lose weight?