Weight Loss :: Belgravia Centre

Your personal information

First Names *

Surname *

What is your email address? *

Confirm your email address *

Privacy

Measurements

Height *

Feet/inches Centimetres

Feet

Inches

Weight *

Stones/pounds Kilograms

Stones

Pounds

Ethnic background *

You can select more than one option.

Asian or Asian British (includes Bangladeshi, Chinese, Indian, Japanese) Black, African, Caribbean or Black British Middle Eastern (Arab, Iranian etc.) Mixed or multiple ethnicities White (British, Irish Traveller etc.) Other ethnic group Prefer not to say

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

Tick all that apply (or select “None”).

None of these illnesses Type II diabetes Hypertension Dyslipidaemia Obstructive sleep apnoea Non-alcoholic fatty liver disease

Medications

Please list any prescription or over-the-counter medications

Allergies

Please list any known allergies

Are you currently pregnant or breastfeeding? *

Women - Yes (pregnant) Women - Yes (breastfeeding) Women - No Men – No, I am a man

Are you trying to conceive? *

Yes No

Have you ever been diagnosed with an eating disorder? *

Yes No

If yes, please provide details *

Have you ever used any weight loss medication? *

Yes No

Please provide details of the weight loss medication(s) you have used

Medication name(s)

Are you using this medication now?

Current use Past use (stopped) Both

When was the last time you took this medication?

How long did you use it?

What was your weight before starting?

Stones

Pounds

Stones/pounds Kilograms

Lowest weight achieved

Stones

Pounds

Stones/pounds Kilograms

Target / desired weight

Stones

Pounds

Stones/pounds Kilograms

Did you regain weight after stopping?

Yes No Not applicable

Reason for stopping (if applicable)

Who provided your weight loss medication?

If you would like to provide your GPs details

Include GP name, clinic, or contact information (if available).

GP details

Weight Loss Questionnaire

About you

Measurements

Medical conditions

Lifestyle

Medication history

Additional information

GP details

Weight Loss Questionnaire

Your personal information

Privacy

Measurements

Ethnic background *

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

Medications

Allergies

Are you currently pregnant or breastfeeding? *

Are you trying to conceive? *

Have you ever been diagnosed with an eating disorder? *

Have you ever used any weight loss medication? *

Please provide details of the weight loss medication(s) you have used

Are you using this medication now?

Did you regain weight after stopping?

If you would like to provide your GPs details