Your journey starts with completing a questionnaire that will be reviewed by one of our GPs. Please complete the information as accurately as possible, so we can assess your suitability for our programme. The information you submit is safe. Data you send via this form is encrypted and is stored securely on MyHealthcare Clinic servers. Remember, your responses will be kept confidential. To get started, please share your name: What is your top motivation for losing weight? I want to keep the weight off this timeI want to improve my healthI want to have more energyI want to change my appearanceI want to participate in activities that I currently can't do Next Thank you for sharing your name and goal. We can help! MyHealthcare will create a personalised path to help you achieve your weight loss goals. You Your expert weight loss team BackNext What measurement would you like to use? cm and kgft and stone [group centimetres] What is your height in cm? [/group] [group feetandinches] What is your height in feet and inches? [/group] [group kilograms] What is your current weight in kg? [/group] [group stonesandpounds] What is your current weight in stone and pounds? [/group] BackNext What sex were you assigned at birth? FemaleMale [group Female] Are you pregnant, breastfeeding or trying for a baby? Please note that our treatment programme is not suitable for use while breastfeeding, pregnant, or currently trying for a baby. PregnantBreastfeedingActively trying for a babyPlanning to conceive in the next 3 monthsNone of the above [/group] BackNext What is your ethnic background? Why we ask for your ethnic background? Individuals with ethnic backgrounds face a higher likelihood of weight-related health issues even at a lower BMI. Our medical professionals consider this factor when evaluating the appropriateness of your treatment. White (Caucasian)Asian (including Indian subcontinentBlack African or African-CaribbeanMiddle EasternLatino / HispanicNot listed BackNext How would you rate your physical fitness? Very goodGoodAdequatePoor BackNext How many hours of physical activity do you do per week? eg. gym, running, swimming or team sports More than 7.5 hours5 - 7.5 hours2.5 - 5 hoursLess than 2.5 hours BackNext Have you been diagnosed with or experienced any of the following? Please choose all that apply Liver disease - not including 'fatty liver'Previous pancreatitisDiabetic retinopathy/ diabetic eye diseaseHeart failureKidney problems (other than kidney stones)Thyroid cancers or a family history of thyroid cancersMultiple endrocrine neoplasia type 2 (MEN2)Type 1 diabetesWeight-loss related surgery in the last 12 monthsGallstonesFast heart rateNone of the above BackNext Please choose all that apply Type 2 diabetesPre-diabetesHigh cholesterol or high triglyceridesHeart disease or peripheral vascular disease, including angina, previous heart attacks, heart failureObstructive sleep apnoeaCOPDPolycystic ovary syndrome (PCOS)Fatty liverHigh blood pressureOtherI have no medical conditions [group OtherAilments] [/group] BackNext Do you take any medications? YesNo [group medications] [/group] Have you ever taken any medication for weight loss? YesNo [group WeightLossMedications] [/group] Do you have any allergies? YesNo [group allergyResponse] [/group] BackNext How would you rate your mood in the last 2 weeks? GoodNeutralLow BackNext Please select any that are true for you I currently have or have previously been diagnosed with eating disorders such as bulimia or anorexia nervosaI sometimes make myself sick (induce vomiting) because I fell uncomfortably fullI think I'm fat when others say I'm too thinNone of the above BackNext Would you like to inform your GP about this treatment? YesNo [group InformGP] Please share the name of your GPs surgery [/group] BackNext Finally, please share your contact details Please indicate preferred contact method PhoneEmail Date of birth Please upload a photo of yourself (please ensure your photo is appropriate and you are clothed) By submitting this form, you agree with the storage and handling of your data by our team. BackΔ
