Weight Loss Follow Up Questionnaire

1. Hi, What is your name?

2. 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

2b. If there has been a gap in treatment please advise for how long and please explain why?

3. 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 doesn’t apply to you.

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

Yes No

4b. What side effects have you experienced, and how severe were they? How long did they last for?

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

If your ordering Nevolat, please advise what dose your currently on.
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?

6. What is your latest BMI?

Enter your height

Metric

cms

Enter your weight

Metric

kgs

Your BMI is: 0

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

Yes No

7b. Please provide more details:

8. We need to let your GP know about your treatment to ensure you get the best level of care possible. Please provide us your GP details.

Please Provide GP Email (preferred):

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9. Are you breast feeding, pregnant or planning to become pregnant?

Women of childbearing age considering taking Wegovy or Mounjaro are recommended to take contraceptives. You must stop using Mounjaro ONE month before trying to conceive, and Wegovy 8 weeks before trying to conceive.

Yes No

9b. Please tell us whether your are breastfeeding OR if you are pregnant: please tell us how many weeks pregnant you are

10. Are you taking any new medications?

Yes No

10b. Please provide more details:

11. We need permission to access your NHS Summary Care Records. Do you give us permission?

Yes

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Weight Loss Follow Up Questionnaire

Prescription & Medical History

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