Manchester Chemist

Secure form

Weight Management Service Eligibility

Please complete this form to check if you are eligible for this service.

Please check the form:

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)

Upload an image of your height using a tape measure or other means

Starting Weight (kg)

Upload an image of your weight by you standing on the scales

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

Blood Pressure (mmHg):

Heart Rate (BPM):

Upload an image of your Blood Pressure and Heart Rate

What's your target weight? (kg)

Manchester Chemist

Manchester Chemist is a trusted online pharmacy (Distant Selling Pharmacy) in Manchester, providing NHS and private healthcare services. Our Manchester pharmacy offers prescriptions, travel vaccinations, blood tests and weight management.

Serving patients across the whole of the UK

Address Unit 11, 20–22 Mary Street
Cheetham Hill
Manchester
M3 1DZ

🚗 Free parking available on-site

Opening Hours

Monday – Friday: 09:00 – 18:00

Saturday: 10:45 – 12:15

Sunday: Closed

Contact0161 222 5790 [email protected]

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