Online Weight Loss Assessment - Personalized Treatment at Dr Vahe Clinic

WEIGHT LOSS MEDICATION

ONLINE ASSESSMENT

We will ask you a few questions to assess your suitability for prescription weight loss medication. The questionnaire takes approximately 3 minutes to complete. While we strive to keep the process simple and thorough, we may need to contact you for additional details if necessary. Please provide accurate information, and if you are unsure about any responses, we recommend consulting your GP before proceeding.

Online Assessment

Please complete the form below.

First Name

Last Name

Email

Phone Number

Address including Postcode

Date of Birth required

Weight (kg)

Height (cm)

Are you currently under medical treatment?

Yes

No

Have you been admitted to hospital or had surgery within the last 2 years?

Yes

No

Are you currently taking any medications?

Yes

No

Do you have any known allergies?

Yes

No

Do you have any conditions that impact your liver, kidneys, prostate, or urinary system?

Yes

No

Are you currently taking any medication to manage high blood pressure (hypertension)?

Yes

No

Are you currently using any medication for a prostate condition?

Yes

No

Are you or your partner currently pregnant or attempting to conceive?

Yes

No

By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that false or misleading information may affect my eligibility for prescription weight loss medication.

Your Signature