BUCKINGHAMSHIRE MEDICAL

Care you need, when you need it

Wegovy
Medical Questionnaire

Complete our short questionnaire if you would like to begin weight loss treatment

First name

Last name

Date of Birth

Select an Address

Phone

Please enter your current weight

Please enter your height

Do you have/ had any of these conditions?

Diabetes

Pre-diabetes

High blood pressure

High cholesterol

Obstructive Sleep Apnoea

Pancreatitis

Heart Failure

None of above

Do you have any other medical conditions not listed above?

Do you currently take any medications, or have you recently finished a course of medications?

Are you allergic to any medicines or other substances?

Have you ever been diagnosed with an eating disorder?

Yes

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

Yes

Women of childbearing potential: Wegovy and all other drugs of this kind (Saxenda, Ozempic etc) have the potential of causing harm to an unborn baby during pregnancy. It is vital that women who could get pregnant use a form of adequate contraception while using these medications. If you plan to become pregnant then you must stop Wegovy at least 2 months before trying to get pregnant.

Please provide the name and address of your registered GP practice

Please read the following, and confirm that you understand and agree

Prescribed weight loss medication is only effective alongside other important lifestyle changes such as eating a low calorie diet and increasing physical activity. If I don't make these changes, I may lose less weight than expected or none at all, and may have to stop treatment.

Our Doctors will take your BMI and all of your medical history into consideration and may prescribe off-label when making a decision about treatment

I declare that the information I’ve provided is accurate and complete, and that this medicaton is for my personal use only. I understand the side effects and effectiveness of the treatment options available.

I have read, understood and agree to Buckinghamshire Medical's Terms & Conditions View Terms & Conditions

Thank you! Our Doctors will review the information and will contact you within 24 hours

BUCKINGHAMSHIRE MEDICAL