Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.About You *FirstLastEmail *Contact Number * *MaleFemaleDate of Birth *Please provide your weight *KgStones/PoundLayoutDropdown (copy) *Stones07 st08 st09 st10 st11 st12 st13 st14 st15 st16 st17 st18 st19 st20 st21 st22 st23 st24 st25 st26 st27 st28 st29 st30 st31 st32 st33 st34 st35 st36 stDropdown (copy) (copy) *Pounds00 lb01 lb2 lb3 lb4 lb5 lb6 lb7 lb8 lb9 lb10 lb11 lb12 lb13 lbDropdown *Weight (Kg)404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250Please provide your height *Feet & InchesCentimetresLayoutDropdown *Feet04 ft05 ft06 ft07 ftDropdown *Centimetres120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200Dropdown *Inches00 in01 in2 in3 in4 in5 in6 in7 in8 in9 in10 in11 inDo you smoke or drink? *YesNoDo you take any medication whether prescribed, over the counter, herbal/alternative or partake in any recreational drug use? *YesNoDo you have any allergies? *YesNoWhat is your blood pressure? *Normal (90/60mmHg to 140/90mmHgHigh (over 140/90mmHg)Low (below 90/60mmHg)Not sureHave you been advised to avoid strenuous exercise? *YesNoAre you able to walk 3 miles or climb a set of stairs without pain in your chest? *YesNoDo you have any history of symptoms of anxiety or depression? *YesNoAbout your symptomsWhat is your goal weight? *Do you have any medical conditions or have any past medical history of note? E.g. surgery, chronic conditions such as PCOS, heart disease, diabetes *YesNoDo you have any of the following medical conditions (Please select all that apply.) *DiabetesPancreatitis or other Pancreas related conditionsInflammed gall bladder or history of gallstonesHeart failure,heart attack, strokeDiabetic KetoacidosisInflammatory Bowel Disease (Ulcerativecolitis, Crohns Disease, or other inflammatory bowel conditions)Conditions affecting your hormone levelsOther medical conditionsNoneAs mental health can be impacted by your body weight, please tell us about your mental health and wellbeing by selecting one of the following statements. (Please select all that apply) *I have never had a a diagnosis of any eating disorders mental health conditionsI have had a diagnosis of a mental health condition such as anxiety or depressionI have had a diagnosis of or think I may be suffering from an eating disorder (anorexia,bulimia, body dysmorphia)Takeaway and fast food are typically high in fats, salt and other additives which can contribute to obesity, high blood pressure and increasing your risk of other conditions such as Heart disease. Select the option which applies best. (Please select all that apply) *I do not eat takeaways or fast food on a regular basisI consume takeaway or fast food once or twice a weekI consume takeaway or fast food more than 3 times a weekSnacks can be a great way to get some much needed energy between meals. Unhealthy snacks such as crisps, chocolate or biscuits however can have a detrimental effect. Select the option which applies best. *I do not eat unhealthy snacks such as crisps, chocolate or biscuits on a regular basisI consume snacks such as crisps, chocolate or biscuits once or twice a weekI consume snacks such as crisps, chocolate or biscuits more than 3 times a weekDo you carry out any regular exercise? (Please select all that apply.) *I do not do any exerciseI carry out 1-2 hours of exercise a week across a number of daysI carry out more than 2 hours of exercise each week across more than 3 daysHave you tried any weight loss medication before? (Please select all that apply) *I have tried Saxenda - daily injectionI have tried Orlistat - Xenical/Alli - capsulesI have taken Wegovy before - weekly injectionOtherI have not tried anything beforeDo you agree to inform us, your GP or seek appropriate medical attention if you suffer from any persistent hoarseness, sore throat, difficulty swallowing or any lumps in your neck? *YesNoWhat is your waist circumference? (Measure your waist circumference just above your belly button, breathe out gently and take your measurement. You can repeat this a few times just to be sure) *Is there any particular treatment you are interested in / prefer? *Orlistat / XenicalSaxendaWegovy -WeeklyOthera. Are you pregnant or planning a pregnancy? *YesNoTaking Semaglutide/Ozempic/Saxenda whilst trying to conceive or during pregnancy can cause a risk to the unborn foetus. It is important to stop such medications at least 2 months prior to trying to conceive or as soon as you discover you are pregnant. Please get in touch if you have any questions.b. Are you breastfeeding? *YesNoGP DetailsWould you like us to inform your GP of your treatment? *YesNoWe recommend informing your GP surgery of any treatment that you are taking to keep your medical records relevant and up to dateAgreementDo you agree to the following? *YesNoYou have answered all of the above questions accurately and truthfully. You understand our prescriber(s) will prescribe medication based on your responses and interactions with Twilight Pharmacy. Any incorrect responses or deliberate acts to misinform may be hazardous to your health. You agree to the terms and conditions, privacy policy and terms of use. You will familiarise yourself with the patient information leaflet included with your order and any other information relayed to you via other means including IM/E-mail/telephone. You will contact us and inform your GP if you experience any side effects to treatment, if there are any changes to your medical history including starting any new medications or new diagnoses, or if your symptoms/medical conditions change in any way. You understand completing a purchase does not guarantee supply of treatment; the final decision to prescribe lies with the prescriber with your best interests, health and appropriateness in mind. You agree to the terms and conditions, privacy policy and terms of use. Submit
