Whipps Cross Hospital
Whipps Cross Hospital Byron Integrated Cardiology Unit
London E11 1RG
Spire London East Hospital
Roding Ln S, Woodford, Ilford, Woodford Green
Nuffield Health at St Bartholomew's Hospital
38 Giltspur St, London EC1A 7BS
St Bartholomew's Hospital
W Smithfield, London EC1A 7BE
map-marker
Health Questionnaire for Program Eligibility
Weight loss form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Full Name
*
Email Address
*
Mobile Phone Number
*
How old are you?
What is your current weight and height?
Do you have a history of any heart conditions, diabetes, or high blood pressure?
Are you currently taking any medications, especially for diabetes, hypertension, or cholesterol?
Have you tried to lose weight before, and if so, what methods did you use?
How would you describe your daily activity level? Do you smoke or consume alcohol?
What does your typical diet look like? Do you follow any specific dietary patterns or restrictions?
Are you aware of and prepared for the potential side effects of Semaglutide, such as nausea or gastrointestinal discomfort?
Is there a family history of thyroid cancer or other significant health issues?
family you Do
What are your main motivations for losing weight, and what are your specific goals?
Do you have any known allergies, particularly to medications, or any conditions that might contraindicate the use of Semaglutide?
Submit
CLOSE