Weight Management Assessment

About you

Let's start with the basics.

We need a few basic details before moving on to your health information.

First name

Last name

Date of birth

Sex assigned at birth This may be relevant to clinical assessment and treatment safety.

UK postcode

Measurements

Your current height and weight.

These measurements help provide context for your weight-management assessment.

Height (cm)

Current weight (kg)

Target weight (kg) optional

BMI is one part of a wider clinical assessment and does not determine treatment suitability on its own.

Your goals

What would you like support with?

Tell us what you're hoping to achieve through a weight-management programme.

Lose weight

Improve overall health

Both

Something else

Have you previously tried to lose weight?

What have you tried previously? optional

Medical history

Tell us about your health.

Select any conditions that apply to you. This information may be important for clinical review.

Additional details optional

Medication & allergies

Are you currently taking medication?

Please provide accurate information about current medicines and known allergies.

Do you currently take prescription or regular medication?

Current medication if applicable

Do you have any known allergies?

Allergy details if applicable

Safety questions

A few important health questions.

These answers may affect whether further clinical assessment is appropriate.

Are you currently pregnant, breastfeeding or trying to become pregnant?

Yes

No

Not applicable

Have you had major surgery or been admitted to hospital recently?

Additional details if applicable

This is not an automated prescribing decision Your answers support an appropriate clinical review. They do not automatically approve or decline prescription treatment.

Previous treatment

Have you used medical weight-management treatment before?

Previous treatment history can be relevant to understanding your circumstances.

Yes

No

Tell us more if applicable

Is there anything else you think a clinician should know? optional

Final step

Confirm your details.

Please confirm that the information you've provided is accurate before submitting your assessment.

Email address

Mobile number

What happens after submission? Your information will be retained for the appropriate next-stage review. Submission does not guarantee that prescription treatment will be offered.

Tell us a little about yourself.

Let's start with the basics.

Your current height and weight.

What would you like support with?

Tell us about your health.

Are you currently taking medication?

A few important health questions.

Have you used medical weight-management treatment before?

Confirm your details.