Consultation - Pills2U

Weight Loss

Weight loss refers to the reduction of body weight, typically through a combination of diet, exercise, and lifestyle modifications. It is often pursued for health reasons, such as reducing the risk of chronic diseases like diabetes, heart disease, and certain cancers, as well as improving overall well-being and quality of life. Effective weight loss strategies focus on creating a calorie deficit, where the number of calories consumed is less than the calories expended. This can be achieved through diet changes and regular exercise. Sustainable weight loss involves making gradual and lasting changes to eating and exercise habits, as well as addressing emotional and behavioural factors that contribute to overeating or sedentary lifestyles.

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. To ensure we provide you with the most effective and appropriate treatment, it is crucial that you provide accurate and complete information about your health during our online consultation process. Accurate information helps us understand your condition better, assess any potential risks, and recommend the best possible medication for your needs. Providing false or incomplete information can lead to inappropriate treatment, potential health risks, and delays in receiving the care you need. Thank you for your cooperation and trust in our services.

Question 1:Please provide your Height and Weight so we can calculate your BMI?

Please select either Metric or Imperial measurements :

Metric (Centimeters and Kilograms)

Imperial (Feet and Pounds)

Height

Feet

Inches

Weight

Stone

Pound

BMI Calculation:

Question 2:Please upload a picture of yourself holding a piece of paper with today's date and your ID (this must show your face and home address)

Only images are accepted.

Image #1

Question 3:Are you aged between 18 - 74 years old?

Question 4:What is your ethnicity?

White, English, Welsh, Scottish or Other

Asian or Black Asian

Black, Black British, Caribbean or African

Middle Eastern

Mixed or multiple ethnicities with an Asian, Black or Middle Eastern background

Other ethnic group

Prefer not to say

Question 5:Do you have any known allergies?

Question 6:Are you currently taking any medication or recently finished a course of medication?

If yes, please list all your current and recent prescription medication including any medication you buy over the counter, online or any recreational drugs you may take?

Question 7:Are you taking any of the following medications?

Amiodarone
Carbamazepine
Ciclosporin
Clozapine
Digoxin
Fenfluramine
Lithium
Oral Methotrexate
Phenobarbital
Phenytoin
Somatrogon
Tacrolimus
Theophylline
Warfarin

Question 8:Do you have any chronic conditions ?

If yes, please list them:

Example include but not limited to:
- High Blood Pressure
- Sleep Apnoea
- Asthma
- High Cholesterol
- Fatty Liver Disease
- Epilepsy
- Type 2 Diabetes / Pre-diabetes / Diabetes
- Health or Weight anxiety
- Polycystic ovary syndrome (PCOS)
- Intolerance to any sugars like galactose intolerance
- Lapp lactase deficiency or glucosegalactose malabsorption)

Question 9:Have you been diagnosed with any of the following conditions/illnesses?

Eating Disorder (current or previous) e.g. Anorexia, Bulimia or Binge Eating
Chronic Malabsorption Syndrome
Kidney Disease
Liver Disease
Severe Gastrointestinal Disorders such as Inflammatory Bowel Disease, Gastroparesis, ulcerative colitis, Crohn's disease
Gallbladder conditions such as Cholelithiasis (Gallbladder Stones) / Cholecystitis (Gallbladder Inflammation) / Gallbladder Removal within last 3 months
Bile Duct or Pancreas Disease
Pancreatitis
Heart Failure
Cancer (current)
Type 1 Diabetes
Diabetic Retinopathy
Type 2 Diabetes with insulin or other diabetes injection or tablet medication (excluding Metformin)

Question 10:Do you or or anyone in your family have a history of medical disorder's within your family e.g. medullary thyroid cancer, thyroid cancer or multiple endocrine neoplasia type 2 (MEN2)?

Question 11:Women Only: Do any of the following apply to you?

Trying to conceive or become pregnant
You are breastfeeding or planning to start breastfeeding
You are pregnant
Is there any chance of you being pregnant
If you are male, answer No

Question 12:Do you have any medical condition or take any medication that may have contributed to your weight gain or ability to lose weight examples include but not limited to:

Acromegaly (body produces too much growth hormone)
Any growth hormone condition or problem such as deficiency or excess
Cushing's Syndrome
Hypothalamic Damage (e.g. tumour / trauma / surgery)

Question 13:Have you ever had any surgery (operations) ? Examples can include but not limited to, Gastric Surgery (bariatric surgery), gastric band surgery or removal, gallbladder removal or any other surgery.

If yes, please provide more details:

Question 14:Do you have a current or previous history of depression, suicidal thoughts, generalised anxiety disorder or any other psychiatric disorder?

2 2. About your Condition

Accurately describing your condition during our online consultation is essential for ensuring you receive the best possible care. Detailed and truthful information about your symptoms, their frequency, and their severity allows our healthcare professionals to make informed decisions about your treatment. Incomplete or incorrect descriptions can result in inappropriate medication, potential health risks, and delays in your care. Your honesty and thoroughness help us provide you with the most effective and safe treatment options. Thank you for your cooperation and trust in our services.

Question 1:Are you currently taking or previously taken any weight loss treatment such as but not limited to Ozempic/Wegovy(Semaglutide) , Mounjaro(Tirzepatide), Saxenda/Victoza (Liraglutide), Xenical(Orlistat)? This can include any over-the-counter treatments

Question 2:Have you ever experienced an allergic reaction or side effects to any weight-loss injections e.g. Ozempic/Wegovy(Semaglutide) , Mounjaro(Tirzepatide), Saxenda/Victoza (Liraglutide) or any other treatment?

Question 3:If you are currently already taking Mounjaro or Wegovy and transferring from another provider please can you kindly provide a picture of the box with pharmacy label details visible. If you do not have the box please provide your current prescription, treatment notification or email showing approval and dispatch with details of the medication and your details. Please ensure this is the most recent dated order.

Only images are accepted.

Image #1

Question 4:What are your weight loss goals? (e.g., lose a certain number of pounds/kilograms, achieve a specific BMI)

3 3. The Agreement and Consent

Please take the time to carefully read the Agreement and Consent statements during our online consultation process. Understanding these statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. The Agreement and Consent sections outline important information about the risks, benefits, and responsibilities associated with your medication. By reading and agreeing to these terms, you help us ensure that you are aware of and comfortable with the treatment plan. Your informed consent is crucial for providing you with the best possible care. Thank you for your cooperation and trust in our services.

Question 1:Have you been referred?

Question 2:Shipping and Agreement For cold-storage items to be sent with courier

We do our best to ship as fast as possible with the best possible courier, but once the delivery leaves us and is with the courier, things are out of our control. Once your order is approved it will be sent via Royal Mail Tracked 24 as standard or you can select DPD Next Day by 12pm or DPD next day Weekend. These are usually dependable and reliable services.

You agree to accept the responsibility of rearranging the delivery in the case of a missed or delayed delivery by Royal Mail/DPD and agree to deal with any missed or delayed deliveries directly with Royal Mail/DPD rather than with the pharmacy. For any deliveries received beyond 2 days of dispatch please contact us prior to opening to check the medication as it may be outside of the cold chain storage conditions which may effect the medication if it is bought in advance of use. Where this is due to missed deliveries due to no one accepting delivery at the delivery address you agree that you will be liable for replacement and that the delivered medication will be disposed of via a local pharmacy. Where the delay is due to Royal Mail/DPD we will contact them to claim and either send replacement or refund accordingly but only once the claim has been approved by Royal Mail/DPD.

For cold-storage items such as Wegovy/Mounjaro you agree for us to send out via Royal Mail Tracked 24 or DPD next Day by 12pm/Weekend delivery with ice packs to maintain the cold chain temperature.

Please note - the stability of the medication cannot be fully guaranteed using this method due to factors out of the control of the pharmacy and the risk and liability is accepted by you as being your risk and liability.

Question 3:Sharing information with your GP or other healthcare professionals for previous/future service providers.

Question 4:Is there anything else you would like to mention that is not included above?

Question 5:Arranging a suitable time and date for video call to verify your weight and height

Question 6:Do you understand and agree to the following?

Question 7:Understanding of risks: I have been informed about the potential side effects and interactions of the prescribed medication for weight loss.

Question 8:Confirmation:

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have serious health implications.

You understand that once you have completed this consultation form, we will process your payment. However, please note that this does not guarantee treatment approval. If we determine that you are not suitable for treatment, we will issue a full refund.

1 About Your Health
2 2. About your Condition
3 3. The Agreement and Consent

Weight Loss

Assessment for Weight Loss

Weight Loss

1 About Your Health

Question 1:Please provide your Height and Weight so we can calculate your BMI?

Height

Weight

Height

Weight

Question 2:Please upload a picture of yourself holding a piece of paper with today's date and your ID (this must show your face and home address)

Question 3:Are you aged between 18 - 74 years old?

Question 4:What is your ethnicity?

Question 5:Do you have any known allergies?

Please provide more information

Question 6:Are you currently taking any medication or recently finished a course of medication?

Please list all your current and recent prescription medication including any medication you buy over the counter, online or any recreational drugs you may take?

Question 7:Are you taking any of the following medications?

Please provide more information

Question 8:Do you have any chronic conditions ?

Please provide more information

Question 9:Have you been diagnosed with any of the following conditions/illnesses?

Please provide more information

Question 10:Do you or or anyone in your family have a history of medical disorder's within your family e.g. medullary thyroid cancer, thyroid cancer or multiple endocrine neoplasia type 2 (MEN2)?

Question 11:Women Only: Do any of the following apply to you?

Question 12:Do you have any medical condition or take any medication that may have contributed to your weight gain or ability to lose weight examples include but not limited to:

Question 13:Have you ever had any surgery (operations) ? Examples can include but not limited to, Gastric Surgery (bariatric surgery), gastric band surgery or removal, gallbladder removal or any other surgery.

Please provide more information

Question 14:Do you have a current or previous history of depression, suicidal thoughts, generalised anxiety disorder or any other psychiatric disorder?

Please provide more information

2 2. About your Condition

Question 1:Are you currently taking or previously taken any weight loss treatment such as but not limited to Ozempic/Wegovy(Semaglutide) , Mounjaro(Tirzepatide), Saxenda/Victoza (Liraglutide), Xenical(Orlistat)? This can include any over-the-counter treatments

Please provide more information

Question 2:Have you ever experienced an allergic reaction or side effects to any weight-loss injections e.g. Ozempic/Wegovy(Semaglutide) , Mounjaro(Tirzepatide), Saxenda/Victoza (Liraglutide) or any other treatment?

Question 4:What are your weight loss goals? (e.g., lose a certain number of pounds/kilograms, achieve a specific BMI)

3 3. The Agreement and Consent

Question 1:Have you been referred?

If so please provide the referral code.

Question 2:Shipping and Agreement For cold-storage items to be sent with courier

Question 3:Sharing information with your GP or other healthcare professionals for previous/future service providers.

Question 4:Is there anything else you would like to mention that is not included above?

Please provide more information

Question 5:Arranging a suitable time and date for video call to verify your weight and height

Question 6:Do you understand and agree to the following?

Question 7:Understanding of risks: I have been informed about the potential side effects and interactions of the prescribed medication for weight loss.

Question 8:Confirmation:

Assessment Progress

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