Weight Loss Follow Up Questionnaire After Consultation

20/03/2025 05/02/2026

Thanks for submitting your consultation. We also ask a few follow-up questions each time you place an order. These help us make the best prescribing decisions based on your current health, medication history, and any changes in your treatment.

Please answer honestly and in full—this allows us to assess your suitability for treatment, ensure you’re on the correct dose, and provide any necessary guidance.

1. Has there been a gap in treatment?

Less than 5 days
More than 5 days
More than 30 days
For Nevolat: Have you had a gap of longer than 3 days?

Yes No

1b. If there has been a gap in treatment please advise for how long and please explain why?

2. If you have sourced your medication doses elsewhere, please upload proof of purchase? Evidence can be either your weight loss medication with a pharmacy/dispensary label, a letter from your previous supplier, or a copy of your previous prescription. The evidence must highlight the patient name, medication ordered, its strength, date ordered and the name of the provider.

Press done if it doesnt apply to you.

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3. Have you experienced any side effects from weight loss medication since your last dose?

Yes No

3b. What side effects have you experienced, and how severe were they? How long did they last for?

4. Can you please advise why you have selected the current dose?

If increasing, have you been tolerating your current dose well?
If decreasing, what made you decide to lower your dose? (e.g., side effects, maintenance, doctor’s advice, etc.)
If the dose is the same can you advise why?
If your ordering Nevolat, please advise what dose your currently on.

5. Has your health condition changed since your last order?

Yes No

5b. Please provide more details:

6. Are you taking any new medications?

Yes No

6b. Please provide more details:

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Weight Loss Follow Up Questionnaire After Consultation

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