Medical History

Your Medical History - Form

This medical information you submit in this form is confidential. It is shared with no one without your permission.
If you link profiles with your G.P. – you give your permisssion for your G.P. to view this information.

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Name

First Last

Your Email(Required)

Your doctor will review your suitability for obesity medication based on his information.(Required)

This questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers, please verify the information with your GP before using the service: I am 18 years old or above. I am using this service on my own behalf and of my own free will. Any treatment or advice is for my sole use only.

I confirm the above statements are true.

Full Medical History Disclosure(Required)

Obesity medication can stop other drugs from working. Certain drugs can interact with obesity medication and cause a serious reaction - please tell us about your drugs when asked. Obesity medication will only work as part of a weight management plan and should only be taken by those who are overweight.

Please confirm that you understand this.

What is your current height (enter as centimeters)?(Required)

What is your current weight (enter as kg)?(Required)

What is your age?(Required)

What sex were you born as? *(Required)

Male

Female

Do you do 3 or more hours of some form of moderate exercise a week?(Required)

Yes

It is recommended that most adults should do at least 150 minutes of moderate aerobic activity such as cycling or walking every week, AND strength exercises on two or more days a week. Strength exercises should work all the major muscles - legs, hips, back, abdomen, chest, shoulders and arms. One way to do the recommended weekly 150 minutes is to split it to 30 minutes, 5 days a week.

Do you do regularly drink alcohol?(Required)

Yes

Alcohol contains a large number of calories and may stop you from losing weight.

Do you Smoke?(Required)

Smoking is very bad for your overall health. You should consider trying to stop this as well.

Have you tried any other weight loss programmes in the past such as dieting or exercise?(Required)

Yes

This medication will not work alone; you need to modify your lifestyle as well. Exercising, eating a lower calorie diet and reducing alcohol are common ways of doing this.

If Yes, please specify which programmes you have tried in the past:

Are you currently taking any weight loss medication?(Required)

Yes

Which weight loss medication are you taking?

How much weight have you lost so far?(Required)

Do you experience any side effects from this medicine?(Required)

Yes

Please give more details of your side effects:

Have you taken any weight loss medication in the past?(Required)

Yes

Which weight loss medication have you taken in the past??

How much weight did you lose?(Required)

Did you experience any side effects from the weight loss mediciation in the past?(Required)

Yes

Please give more details of your side effects in the past:

Have you been diagnosed with high blood sugar levels or diabetes?

Yes

If Yes, please specify high sugar or diabetes diagnosis:

Do you currently suffer from either heart disease, high blood pressure or are you being prescribed a treatment for high blood pressure?

Yes

If YES, I DO, please specify current heart disease or high blood pressure issues:

Have you ever suffered from obstructive sleep apnoea?(Required)

Yes

If YES, I HAVE, please specify obstructive sleep apnoea issues:

Are your daily activities currently affected by your weight?

Yes

If yes, please specity how you are affected:

Even after being rested, do you still feel tired and lacking energy?(Required)

Current and recent use of medicines Do you take any of the following?

The Contraceptive Pill(Required)

Yes

If you get diarrhoea with obesity medication the contraceptive pill will not work and you should follow the missed pill advice in the information leaflet that accompanies your pill.

Ciclosporin(Required)

Yes

You should not take obesity medication - it will reduce the effect of your Ciclosporin

Warfarin or DOAC (also known as a Direct Oral Anticoagulant or NOAC) such as Apixaban, Rivaroxaban, Edoxaban or Dabigatran(Required)

Yes

It's possible that Wegovy could impact the way that blood thinning medications like Warfarin and other anticoagulants work in the body. Although research on these interactions is limited, using Wegovy could increase your risk of experiencing adverse bleeding events

Epilepsy Medication(Required)

Yes

You should not take obesity medication - it will increase the risk of seizures.

Thyroid Medication(Required)

Yes

You should not take obesity medication - it will increase the risk of a low thyroid level (hypothyroidism).

Medicines for the treatment of HIV(Required)

Yes

You should not take obesity medication - it it can reduce the effect of your HIV medications.

Amiodarone(Required)

Yes

You should not take obesity medication - it it can reduce the effect of your Amiodarone.

Are you taking any prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?(Required)

Yes

Please give more details regarding current medication or recreational drugs.

Are you allergic to any of the following? Please select all that apply.

Penicillin

Grass, pollen, trees, plants (hay fever)

House dust

Animals (Dogs, cats, horses. etc.)

Nuts

Do you have any other known allergies?(Required)

Yes

Please give all your allergies(Required)

Your medical history

We need to check if you are at risk of heart disease. Please tick all that apply:(Required)

I am a man over the age of 40

I am a post-menopausal woman

I have high cholesterol

I have high blood pressure

I have diabetes

I have sleep apnoea

My father / brother had heart disease at less than 55 years old

My mother / sister had heart disease at less than 65 years old

None of the above

Have you ever been diagnosed with a problem of absorbing your food, sometimes called chronic malabsorption syndrome?(Required)

Yes

Please give more details regarding chronic malabsorption syndrome?

Do you have a history of kidney or liver disease?(Required)

Yes

Please give more details about history of kidney or liver failure:

Have you ever been diagnosed with gallbladder, bile duct or pancreas disease?(Required)

Yes

Please give more details about your for gallbladder, bile duct or pancreas disease?

Have you ever had any form of gastric surgery, such as removal of any part of your GI tract?(Required)

Yes

Please give more details about your gastric surgery

Do you have or have you ever been diagnosed with an eating disorder such as anorexia or bulimia?(Required)

Yes

Please give more details about your diagnosis for an eating disorder such as anorexia or bulimia(Required)

Are you pregnant or planning to become pregnant within the next six months?(Required)

Yes

Please give more details about pregnancy:

Are you breastfeeding?(Required)

Yes

Please give more details about your breastfeeding:

Have you noticed it difficult when it comes to thinking, remembering or making decisions?(Required)

Do you feel sad or anxious for 2 weeks or more on a continuous basis?(Required)

Yes

If, YES I DO, please specify about your recent feelings:

Name

First Last

This must be the same name as appaears on your formal ID.

Home Address(Required)

Street Address Address Line 2 City / Town State / County Zip / Eircode Country

Your address is needed for any medication prescribed.

Phone Number(Required)

This informtion is used for professional contact only.

Please choose a Pharmacy for prescription fulfillment.

Prescriptions are sent electronically to the pharmacy of your choice. Please enter the pharmacy name, street, town and county where you want your prescription to be sent.

Personal Video - Please record directly. (Optional)

We recommend you upload a personal video so the Doctor can see how you are doing.

This field is hidden when viewing the form

Approved? (Admin-only)

Approved

I confirm that I have understood fully and read in full all of these questions and that my answers are true and accurate, to the best of my knowledge.(Required)

YES

I give my permission for the information I have submitted in this form to be viewed by my G.P. (if we have linked profiles).(Required)

YES