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Canary Wharf and Birmingham! New patient in-clinic GP appointment only £20! Use code NEW2023 when booking.

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Struggling to lose weight? Join our waiting list! Start your free eligibility assessment here.

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.

Your details

Your contact details

Date of birth

Please indicate preferred contact method

PhoneEmail

What measurement would you like to use?

cm and kgft and stone

What is your height in cm?

What is your height in feet and inches?

What is your current weight in kg?

What is your current weight in stone and pounds?

What sex were you assigned at birth?

FemaleMale

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

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

How would you rate your physical fitness?

Very goodGoodAdequatePoor

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

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

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

Do you take any medications?

YesNo

Have you ever taken any medication for weight loss?

YesNo

Do you have any allergies?

YesNo

How would you rate your mood in the last 2 weeks?

GoodNeutralLow

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

Would you like to inform your GP about this treatment?

YesNo

Please share the name of your GPs surgery

By submitting this form, you agree with the storage and handling of your data by our team. Please wait for the form to refresh after pressing submit.

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Dr Sophie Burton

General Practcioner

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