Weight loss treatment eligibility form

Title

First Name

Last Name

Date of Birth

Gender
MaleFemaleOtherPrefer not to Say

Home Address

Phone Number

Email Address

GP Practice Name

As part of the initial consultation, we are going to ask you about your medical history. Your answers will help us assess your suitability for treatment.

Medications like Mounjaro® and Wegovy® have the potential to cause serious illness and severe side effects if used inappropriately, and our clinicians will not be able to assess your health risks if false or inaccurate information is provided. Please answer all questions honestly and in full.

Mounjaro® and Wegovy®

• Are once weekly injections for weight loss and weight maintenance

• Act on receptors that control your appetite, making you feel fuller, less hungry and reduces cravings for food

• May help you eat less food, which may help you lose weight

• Are most effective when used alongside a healthy lifestyle, including managing a healthy balanced diet and regular exercise

• Treatment starts at a low dose which gradually increases over 16 to 20 weeks

• Can only be used: i) if you have a body mass index (BMI) of 30 or more OR ii) 27 or more with a weight-related health problem.

• May cause side effects like nausea, vomiting or diarrhoea

Before you continue, please check the following important information:

• Your medication will ONLY be issued once the clinician is satisfied that you meet the criteria and clinical safety checks are completed.

• Weight loss medications are not a replacement for a healthy lifestyle, and should be used alongside a calorie-controlled diet and increased physical activity.

• Only one type of weight loss medication can be used at the same time.

• If your body mass index is over 40, other treatments like bariatric surgery may be more beneficial. To consider your other options you should speak to your doctor.

• You understand that if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop treatment and speak to your doctor.

• Weight loss and weight loss treatment have been associated with lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental issues), you should stop the treatment and inform the clinical team at Jenhams or your doctor.

Do you agree and consent to the following:

• You are completing this consultation for yourself and to the best of your knowledge.

• You will disclose any medical conditions, serious illnesses or operations you have had.

• You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time.

• You are registered with a GP in the UK and agree to sharing the outcome of this questionnaire and consultation

• Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.

Do you understand and agree to the above?*
YesNo

Ethnicity

Healthy BMI ranges are different according to your ethnic background. Our clinicians will carefully evaluate your BMI and complete medical history to determine the most appropriate treatment.

Which ethnicity are you?
Asian or Asian BritishBlack or Black British including African, Caribbean or any other Black backgroundMixed ethnicityWhiteOther

Height and Weight

Eligibility for a weight loss injection relies on Body Mass Index (BMI) thresholds. BMI is calculated using your weight and height.

Height

Weight

BMI

The following conditions are often weight related and may be improved as a result of losing weight. If you do have any one of these conditions, the threshold BMI for consideration of treatment is reduced to 27 or greater. Please select any relevant conditions:
I have Pre-diabetesI have Insulin resistanceI have Obstructive sleep apneaI have Cardiovascular disease, e.g. history of stroke, angina, ischaemic heart diseaseI have Hypertension (High blood pressure)I have Dyslipidemia (High cholesterol)I have Non-alcoholic fatty liver diseaseNone of these statements apply to me

Dis-Qualifying Conditions

These conditions can lead to serious complications when losing weight or taking weight loss medications. You are unlikely to be eligible to purchase a weight loss injection and we recommend a separate consultation with one of our doctors.

Do any of the following statements apply to you?*
I have chronic malabsorption syndrome (problems absorbing food)I have cholestasis or Gallbladder, Bile duct or Pancreas disease (especially pancreatitis)I’m currently being treated for cancerI have diabetes requiring insulin or other injectable medicationI have diabetic retinopathyI have severe heart failureI have a family history of thyroid cancer and/or I’ve had thyroid cancerI have end-stage kidney diseaseI have Multiple Endocrine Neoplasia type 2 (MEN2)I have a history of pancreatitisI have or have had an eating disorder such as bulimia, anorexia nervosa, or a binge eating disorderI have had surgery or an operation to my thyroidI have had a bariatric operation such as gastric band or sleeve surgeryI am pregnant or planning to be pregnantI am breast feedingI have Severe gastrointestinal diseases (inflammatory bowel disease such as Colitis, Crohn’s, Ulcerative Colitis, Coeliac disease or paralysis of the stomach)I have a blood clotting diseaseI have a bleeding disorderI have uncontrolled severe depressionNone of these statements apply to me

Medical History

Do you have any other medical conditions?*
YesNo

If yes, then please list your other medical conditions in this box:

Medications

Do you take any medication including prescriptions, over the counter, supplements and any recreational drugs*
YesNo

If yes, then please list the regular medication you take in this box.

Do you have any known drug allergies? If yes, please state name of drug.*

Summary Care Record (Optional)

We want to provide you with the right prescription, quickly and safely. To help us do that, our healthcare team would like to request access to your Summary Care Record (SCR) – a short record of key health information, such as your medications and allergies. We will only access it if we need to clarify anything to check the treatment is safe for you.

Can We Access Your Summary Care Record (SCR)?*
YesNo

Any Previous weight loss injection use

Have you ever taken any of the following medications to help you lose weight?
MounjaroWegovyOzempicOtherI have never taken medication to lose weight

• I am fully aware that some products are not licensed for weight-loss
• I am fully aware that products licensed for weight-loss have strict criteria for their use but may be used off-license
• I am not pregnant or breast-feeding
• I will notify my GP of starting a weight-loss injection regimen and I consent Jenhams Clinic contacting my GP
• I agree that I may not be suitable for treatment and the clinician's decision is final
• I agree that if I am not prescribed a weight loss injection (Mounjaro) during my consultation then a £40 consultation charge will be applied. This fee is waived if an injection is prescribed.
• I consent to Jenhams Clinic storing my medical history and data that will not be shared with any third parties.
• I am the patient who will be taking this medication and is not for someone else.
• I accept terms and conditions
• I have read Jenhams Clinic terms and conditions on: https://www.jenhamsclinic.co.uk/terms-and-conditions

Agree to all of the above*
YesNo

Please enter your signature here.