Are you between the ages of 18 and 74?

If you have diabetes, are you on any injections or tablets to control your blood sugar, other than metformin?

Have you experienced an allergic reaction before?

Have you ever suffered with an eating disorder?

Are you pregnant, breastfeeding, or trying to conceive?

Have you been diagnosed with any of the following?

• Acromegaly or any growth hormone problem
• Chronic Malabsorption Syndrome
• Cushings Syndrome
• Gallbladder, Bile duct or Pancreas disease
• Gastric surgery (bariatric surgery)
• Heart disease (e.g. ischaemic heart disease, heart attack, heart failure)
• Hypoglycaemia
• Kidney Disease
• Liver Disease
• Multiple Endocrine Neoplasia
• Pancreatitis
• Severe gastrointestinal disease (e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease)
• Thyroid Cancer

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Are you taking steroids or medication to treat your thyroid?

Are you currently taking any medication for weight loss?

Are you currently in the 20th to 24th week of continuous treatment with injectable weight loss medication?

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Do you understand that GLP-1 injectable weight-loss medication may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment?

Do you understand that this medication should not be used by women that are either trying to conceive or are within two months of starting to try for a child?

Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?

Do you understand that injectable weight loss medications should not be used with other weight loss medications?

Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?

Do you understand that weight loss has been associated with a lowering of mood (depression), and if you are experiencing this, you should stop the medication and speak to your doctor?

Do you understand that you need to stop this medication 7 days before any major elective surgery.

Are you registered with GP in Uk?