Better Meds

Do you confirm that:

You understand that it is in your best interests to answer all questions in full, providing accurate and honest information.
You are using this service yourself, of your own free will and any medicine is for your personal use only.
You have capacity to understand all about the condition and medication information we have provided in advance and that you give fully informed consent to the treatment option provided in your best interests.
You have read and fully understand what this medicine is used for, as well as all the possible treatment options for your condition and are aware of all the possible benefits, risks or side effects.
You agree to read the patient information leaflet before taking any medicine and use the medication only as directed.

Yes

People of certain ethnicities may be suitable for treatment at a lower BMI than others, if appropriate. Do any of the following apply to you?

African-Caribbean
Black African
Chinese
Middle Eastern
South Asian
Other Asian

Yes

Prefer Not To Say

Weight

Have you previously taken any medicine to help with weight loss?

Yes

Which weight loss medicine did you use most recently?

Wegovy

Saxendra

Rybelsus

Mounjaro

Ozempic

Mysimba

Xenical/Orlistat

Other

How many calories do you think you consume daily?

Less Than 1500

1500 - 2000

2000 - 3000

3000 - 4000

More Than 4000

I know the exact amount

I don't count calories

Not Sure

How do you monitor what you eat?

How many times a week do you exercise for more than 20 minutes?

Little or no exercise

1 to 2 times

3 to 4 time

5 to 6 times

7 times+

Not Sure

Are you comfortable using an injection pen?

Yes

No, I prefer a tablet

Have you been diagnosed with high blood pressure (with or without treatment)?

Yes

Which medication(s) do you take?

Do you have any allergies?

Yes

Not Sure

Please provide more information.

Have you ever had any medical conditions or surgery not previously mentioned in this form, or is there any further information you would like to provide the doctor?

Yes

Please provide more information.

People with weight-related medical conditions may be suitable for treatment at a lower BMI than other patients, if appropriate. Do you have any of the following weight-related conditions?

Asthma
Chronic back pain
Fatty liver disease
Gallbladder disease
Heart disease (this includes high cholesterol, heart attack, stroke, coronary artery disease)
Osteoarthritis or gout
Polycystic Ovarian Syndrome (PCOS)
Sleep apnea

Yes