Start your weight loss journey – Longfield Polyclinic

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 medication you currently take, and only use one treatment at a time

You accept our Terms & Conditions and Terms of Sale.

Understand that your health records contain confidential patient information, which may be used to help with research, planning, and marketing.

I agree

What is your gender?

Male

Female

Date of Birth:

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

Yes

No

Height (in cm):

Weight (in kg):

What is your ethnic background?

Asian or Asian British

Black (Caribbean, African)

Mixed ethnicities

Other ethnic group

White

Do you currently have or have ever been diagnosed with an eating disorder?

Yes

No

Do you have medication controlled diabetics?

Yes

No

Do you take any other medications?

Do you have any of the following conditions? (Tick all that apply)

Prediabetics

Raised Cholesterol

Osteoarthritis (OA)

Polycystic Ovarian Syndrome (PCOS)

Hypertension (Raised Blood Pressure)

Obstructive Sleep Apnoea (OSA)

Do you have a history of gallstones or pancreatitis?

Yes

No

Do you have or have you ever been diagnosed with thyroid medullary cancer or Multiple Endocrine Neoplasia?

Yes

No

Do you have any allergies to any medications?

Yes

No

Congratulations!!!! You are eligible for FREE GP Video Consultation
Please enter your details below so that our GP will contact you to discuss with your weight loss treatment

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