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Weight Management Form
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This field is for validation purposes and should be left unchanged.
Preferred Pharmacy Location
(Required)
Which Davidsons Chemists would you like to attend for this service?
Please Select
McPhersons Pharmacy (Broughty Ferry)
Safety Screening
This service is for weight management in adults without diabetes and without certain medical conditions where GLP-1 medicines are unsuitable. If you answer “Yes” to any of the questions below, this service is not appropriate for you, and you should contact your GP for further advice.
To move forward, you’ll need to meet the criteria listed below; only if you do, the "Next" button will appear automatically at the bottom of this page.
Are you under 18 or over 84 years old?
(Required)
Yes
No
Have you ever been diagnosed with Type 1 or Type 2 diabetes?
(Required)
Yes
No
Are you currently pregnant?
(Required)
Yes
No
Are you currently breastfeeding?
(Required)
Yes
No
Are you planning to become pregnant within the next 3 months?
(Required)
Yes
No
Unsure
Have you ever been diagnosed with an eating disorder?
(Required)
Yes
No
Have you ever been diagnosed with pancreatitis?
(Required)
Yes
No
Do you have a personal or family history of medullary thyroid cancer (MTC)?
(Required)
Yes
No
Have you been diagnosed with Multiple Endocrine Neoplasia type 2 (MEN2)?
(Required)
Yes
No
Have you previously had a serious allergic reaction to a GLP-1 medication (e.g. semaglutide, tirzepatide, liraglutide)?
(Required)
Yes
No
BMI Eligibility Check
Before we begin, we need to check if you are eligible for this service based on your Body Mass Index (BMI). If you're unsure of your weight or height and are unable to measure them yourself, please visit the pharmacy, and we'll be happy to take these measurements for you before you complete this assessment form.
Weight (kg)
(Required)
Please enter your weight in Kg
Height (cm)
(Required)
Please enter your height in cm
This field is hidden when viewing the form
Hight Sq
Your calculated BMI
Waist circumference (cm)
(Required)
Waist circumference helps assess central obesity and cardiovascular risk. Wrap a tape measure around your belly at the halfway point between the bottom of your ribs and the top of your hips (just above the belly button).
Please indicate if you have any of the following medical conditions (tick all that apply):
(Required)
High blood pressure
High cholesterol
Obstructive sleep apnoea
Cardiovascular disease
None of the above
Unfortunately, your BMI does not meet the minimum threshold required for our weight management service.
This service is intended for individuals with a BMI of 27 or above.
You are eligible to proceed with this assessment. Please complete the remainder of this form.
Please answer honestly. If you are unsure about any part, our Pharmacist will be happy to clarify.
You are eligible to proceed with this assessment. Please complete the remainder of this form.
Please answer honestly. If you are unsure about any part, our Pharmacist will be happy to clarify.
You are eligible to proceed with this assessment. Please complete the remainder of this form.
Please answer honestly. If you are unsure about any part, our Pharmacist will be happy to clarify.
You are eligible to proceed with this assessment. Please complete the remainder of this form.
Please answer honestly. If you are unsure about any part, our Pharmacist will be happy to clarify.
You are eligible to proceed with this assessment. Please complete the remainder of this form.
Please answer honestly. If you are unsure about any part, our Pharmacist will be happy to clarify.
Unfortunately, based on your BMI being between 27 and 30, and the absence of relevant medical conditions, you are not currently eligible for this service.
If your BMI is 40 or above, our pharmacy-led weight management service may not be the safest or most effective option for you.
People with a BMI in this range often need specialist support from NHS services that include doctors, dietitians, and other health professionals.
We recommend speaking to your GP about a referral to a local Tier 3 weight management service.
Your Details
Name
(Required)
Miss
Mr.
Mrs.
Ms.
Dr.
Prof.
Rev.
Title
First name
Last name
Address
(Required)
Street Address
City / Town
Postcode
Phone Number
(Required)
Email Address
(Required)
Date Of Birth
(Required)
DD slash MM slash YYYY
Biological sex
(Required)
(as assigned at birth)
Female
Male
Intersex
Prefer not to say
Ethnic background
(Required)
(please tick one)
White
Mixed or Multiple ethnic groups
Asian or Asian British
Black, Black British, Caribbean or African
Other ethnic group
Prefer not to say
Name and Address of GP
(Required)
For governance and patient safety reasons, we routinely inform your GP when initiating treatment for weight management.
(Required)
I consent to my GP being informed
I decline GP notification
Medical History
Do you have, or have you ever been diagnosed with any of the following medical conditions?
(Required)
(tick all that apply)
Diabetic retinopathy
Gallstones or Gallbladder disease
Kidney impairment or disease
Liver disease or abnormal liver function
Severe gastrointestinal disease (e.g., gastroparesis)
Cardiovascular disease (e.g., heart attack, heart failure, stroke, angina)
Depression or significant mental health conditions
Personal or family history of pancreatic cancer
Recurrent severe nausea or vomiting
Inflammatory Bowel Disease (e.g. Crohn's, ulcerative colitis)
Severe gastro-oesophageal reflux disease
Other
None
Please specify
(Required)
As you have selected other above please provide details
Have you ever had bariatric surgery or been prescribed weight loss medication?
(Required)
Yes
No
If yes, please specify the medication or procedure and the date
(Required)
Have you experienced any recent unexplained weight loss?
(Required)
Unexplained weight loss may indicate an underlying condition that needs investigation.
Yes
No
Do you have any scheduled or upcoming surgical or medical procedures?
(Required)
This is important as medications may affect gastric emptying and anaesthetic safety.
Yes
No
Please give details of scheduled or upcoming surgical or medical procedures
(Required)
Medication Use
Are you currently taking any of the following?
(Required)
Insulin
Sulfonylureas (e.g., gliclazide, glibenclamide)
Any GLP-1 receptor agonist (e.g., Ozempic, Wegovy, Saxenda)
Any weight loss medication (prescribed or over the counter)
Any herbal or supplement products for weight loss
Corticosteroids (oral or injected)
Antidepressants or antipsychotics
Warfarin or other anticoagulant
Other not listed
None
Other Medication(s)
(Required)
Allergies
Do you have any known allergies?
(Required)
Yes
No
If yes, please detail of allergies
(Required)
Hormonal Contraception
Are you currently using any form of hormonal contraception?
(Required)
Yes
No
If yes, which type are you using?
(Required)
(Tick all that apply)
Combined oral contraceptive pill
Progestogen-only pill
Contraceptive patch
Vaginal ring
Injectable contraception
Implant
Hormonal intrauterine system (IUS / hormonal coil)
Other
If Other (please specify):
(Required)
If you are taking an oral contraceptive pill (combined or progestogen-only), what is it being used for?
(Required)
Contraception only
Management of another medical condition (e.g. ovarian cysts, PCOS, endometriosis, heavy menstrual bleeding)
Both contraception and medical management
Unsure
If used for a medical condition, please provide details:
(Required)
Lifestyle and Motivation
What are your main goals for weight management?
(Required)
What percentage weight loss are you hoping to achieve?
(Required)
5–10%
10–15%
More than 15%
Unsure
Have you tried any lifestyle or diet changes in the last 6 months?
(Required)
Yes
No
Please describe the lifestyle or diet changes made
(Required)
Are you willing to make lifestyle changes alongside this treatment (e.g., diet, physical activity)?
(Required)
Yes
No
Do you consume alcohol?
(Required)
Yes
No
Average units consumed per week:
(Required)
One unit is a half a pint of lower-strength beer or cider, a single measure of spirits (25ml), or two-thirds of a small glass of wine.
Do you smoke/vape?
(Required)
Yes
No
If yes, how much per day?
(Required)
Declaration
Consent
(Required)
I agree to the following to complete assessment:
I confirm that I have answered all questions honestly and provided accurate, up-to-date medical information to help safely assess my suitability for this service.
I give my consent for the Pharmacist to access my medical records if needed via the NHS Clinical Portal or Emergency Care Summary. (These are secure systems used by our pharmacists to view relevant medical information such as medications, allergies, and recent treatments to ensure safe care decisions are made.)
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