Manchester Chemist

Clinical Questions

1) Do you have any allergies? *

Yes

No

If yes, please specify

2) Are you pregnant or breastfeeding? *

Yes

No

If yes, please specify

3) Do you have diabetes or prediabetes? *

Yes

No

If yes, please specify

4) Have you been told that you have high blood pressure? *

Yes

No

If yes, please specify

5) Have you been told that you have high cholesterol? *

Yes

No

If yes, please specify

6) Have you ever had any problems with your kidneys or liver? *

Yes

No

If yes, please specify

7) Have you ever been diagnosed with heart failure? *

Yes

No

If yes, please specify

8) Have you ever had pancreatitis? *

Yes

No

If yes, please specify

9) Do you have epilepsy or a history of seizures? *

Yes

No

If yes, please specify

10) Have you ever been diagnosed with an eating disorder? *

Yes

No

If yes, please specify

11) Do you have inflammatory bowel disease or gastroparesis? *

Yes

No

If yes, please specify

12) Have you ever been diagnosed with a mental health disorder? *

Yes

No

If yes, please specify

13) Do you have polycystic ovarian syndrome or Cushing’s syndrome? *

Yes

No

If yes, please specify

14) Do you currently have any problems with your gall bladder? *

Yes

No

If yes, please specify

15) Do you have any other medical conditions? *

Yes

No

If yes, please specify

16) Do you currently take medications prescribed by a doctor, or bought over the counter from a pharmacy? *

Yes

No

If yes, please specify

Physical Assessment

Patient Height (cm)

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Starting Weight (kg)

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BMI (kg/m2) - Leave blank if unsure:

Blood Pressure (mmHg):

Heart Rate (BPM):

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What's your target weight? (kg)

Weight Management Service Eligibility