How old are you?

What is your ethnicity?

What is the gender you were assigned at birth?

Do any of the following statements apply to you:

• I am currently pregnant
• I am trying to get pregnant
• I am breastfeeding

Have you ever been diagnosed with diabetes?

What diabetes type do you have?

Do any of the following statements apply to you:

• Managed by diet and lifestyle
• Managed with Metformin alone
• Managed under a secondary care provider
• Managed with any multiple medications
• Managed with insulin
• Managed with Sulfonylureas
• Managed with DPP-4 Inhibitors (gliptins)
• You have kidney problems
• Have a recent history of diabetic ketoacidosis (Within the last 6 months)
• With a recent history of hypoglycemia (Within the last 6 months)
• Under current review by your GP for diabetes
• You have Diabetic retinopathy

Please confirm if any of the following statements apply to you:

Do you have any of the following conditions?

• Eating disorder or history of disordered eating
• Gastrointestinal disorders
• Pancreatitis
• Active gallstones or cholestasis
• Liver health issues
• Kidney disease
• Respiratory health issues
• Cardiovascular disease
• High cholesterol (dyslipidemia)
• Cancer
• Bone/joint health issues
• History of surgery
• Mental health concerns
• Men's health issues

Do you have any of the following conditions?

When did your bariatric operation take place?

Please confirm the following details about your bariatric surgery:

• When did you get the surgery?
• What type of bariatric surgery did you have?
• Were there any post-surgery complications?
• Are you undergoing any ongoing monitoring?
• What was your BMI before your surgery?
• Are you still losing weight?

Please tell us more information about your thyroid surgery:

• What was the outcome of your surgery?
• Was there any ongoing monitoring after the surgery was completed?

Please let us know more about your mental health condition and how it's being managed:

Do you currently have Acute Kidney Injury (AKI)?

When did you have Acute Kidney Injury (AKI)?

Do you have any other medical conditions that have not been listed?

Please let us know more about any medical conditions you have:

Have you previously taken, or are taking, any of the following weight loss medication:

• Mounjaro
• Wegovy
• Ozempic
• Saxenda
• Alli
• MySimba

Have you ever taken, or are currently taking, any of the following weight loss medications?What is your ethnicity?

Are you still taking Mounjaro?

Are you still taking Wegovy?

What was your most recent, prescribed dose of Mounjaro?

What was your most recent, prescribed dose of Wegovy?

Do you want to continue taking Mounjaro?

Do you want to continue taking Wegovy?

Are you experiencing any side effects?

Please tell us more about your side effects:

• What side effects are you experiencing?
• How severe are they?
• How long do they last?
• Any other details that may help us.

Do you currently take any other medication or have any allergies that you have not yet disclosed on this form?

Please outline any of the allergies you have or any other prescription medication you are taking:

Is there any other information you feel would be useful for our clinicians to know about?