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Weight Loss Assessment

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

STOP. The patient must fill in this consultation.

3. Are you aged between 18-74?

The Family Chemist does not supply medication to under 18s. Weight loss treatments are not licensed for patients over 74.

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

Women of childbearing age considering taking Wegovy are recommended to take contraceptives. You must stop using Wegovy TWO months before trying to conceive.

4b. Please tell us whether your are breastfeeding OR if you are pregnant: please tell us how many weeks pregnant you are

5. What is your BMI?

Please Note: Weight loss treatments are only licensed for patients with a BMI>30kg/m2 or ≥27 kg/m² in the presence of at least one weight-related comorbidity such as pre-diabetes or type 2 diabetes mellitus, hypertension, dyslipidaemia or obstructive sleep apnoea.

Foot
Inches
st
lb
Cms
KGs

Your BMI is: 0

6. We highly recommend you upload a picture of you standing on weighing scales to help our prescribers make an informed prescribing decision safely. (Optional)

7. Do you smoke?

7b. Would you like information on stopping smoking?

8. Do you drink alcohol?

8b. Would you like information on safe alcohol use?

9. Have you ever been prescribed or currently taking weight loss medication or undergoing a low energy diet plan?

The Family Chemist will only deliver Wegovy or Mounjaro if you have titrated your dose correctly. You MUST start from 0.25mg or 2.5mg and work your way up. This is to reduce unwanted side effects and risk of serious illness. You will be asked for evidence if you order a higher strength.

9b. Please let us know what medication/diet plan you have taken or currently taking. Please specify whether you are currently taking the medication or previously taken and why you stopped taking the medication.

10. Do you or have you ever suffered from an eating disorder such as Bulimia Nervosa or Anorexia?

10b. Please provide more details.

11. Do you have any of the following conditions?

  • cholestasis or chronic malabsorption syndrome
  • Severe congestive heart failure or high blood pressure
  • Thyroid disease or thyroid cancer or family history of thyroid cancer or MEN2
  • Inflammatory bowel disease such as ulcerative colitis, crohns disease or diabetic
  • gastroparesis.
  • Type 1 or 2 Diabetes.
  • Gallbladder, gallstones or bile problems
  • Pancreatitis
  • Polycystic Ovarian Syndrome (PCOS)
  • Electrolyte imbalance

11b. Please let us know what condition(s) you have:

12. Do you take any of the following medication?

  • Anticoagulants to thin the blood such as; Warfarin, Rivaroxaban
  • Amiodarone
  • Thyroid Medication
  • Vitamin A, D, E or K supplements
  • Ciclosporin
  • Anti-retroviral medications such as tenofovir, efavirenz, abacavir or emtricitabine
  • Acarbose
  • Epilepsy Medication
  • Oral Contraceptives
  • Diabetes or polycystic ovaries medication or insulin

12b. Please let us know what medication you take:

13. Do you exercise 4-5 times a week for 30 minutes?

Exercising could include walking, running, cycling, swimming.

14. How many calories do you believe you consume daily?

Weight loss treatments are only effective with a low-calorie diet and exercise plan.

15. Do you have any kidney or liver impairment?

15b. Please provide more details:

16. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

16b. Please provide more details:

17. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

17b. Please provide more details:

18.  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.

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19. I agree that: Stock for Mounjaro, Wegovy and Saxenda is limited and intermittent. We cannot guarantee the ongoing supply and cost of any strengths. Supply is subject to availability.

20. FAO MOUNJARO PATIENTS ONLY: I understand that I will need needles, swabs and a sharps bin to use Mounjaro

They can be purchased here:

Needles, Swabs, Sharsbin

ALL OTHER PATIENTS PLEASE CLICK “YES” TO CONTINUE

21. I agree to the following:

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

For Mounjaro, Wegovy and Saxenda Patients

  • Mounjaro and Wegovy is administered once a week whereas Saxenda is administered once daily at any time.
  • Mounjaro, Wegovy and Saxenda are for subcutaneous use only. It must not be administered in any other way. It should be injected in the stomach area (abdomen), upper leg (thigh) or upper arm. I have watched the video on how to use and administer Saxenda.
  • I will not share my pen with anyone else as it may not be suitable for them and can cause infections.
  • I will store my pens in a fridge (2°C to 8°C) to maintain the cold chain. The pen currently in use can be kept out of the fridge for up to one month under 30°C.
  • Mounjaro, Wegovy and Saxenda can cause dehydration. To avoid dehydration, I will drink at least 2 litres of water a day.
  • Mounjaro, Wegovy and Saxenda are used for weight loss in addition to diet and exercise in adults aged 18 and above.
  • I will stop using Mounjaro, Wegovy or Saxenda if I fail to lose 5% of my body weight whilst taking 12 weeks of full dose of (15mg), Mounjaro, (2.4mg) Wegovy or (3mg) Saxenda.
  • I have read the patient information leaflet before purchasing Saxenda.
  • I have read the patient information leaflet before purchasing Wegovy.
  • I have read the patient information leaflet before purchasing Mounjaro
  • I understand that the delivery must be accepted on the first delivery attempt (within 24 hours). This is a temperature-controlled item and will be sent with ice packs and a temperature-controlled pouch. Orders placed after 2 pm on Thursdays will be dispatched the following Monday.

 

  • The Family Chemist clinician may call from time to time to ensure you are taking your medication as prescribed and to provide more advice and guidance.

22. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can discuss your options.

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.