Weight management consultation booking form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of birth MM DD YYYY Telephone Number * Email * Ethnicity White Asian Asian British Mixed Ethnicity Other Black Sex assigned at birth Male Female Weight (kg) * Height (cm) * Have you been diagnosed with Diabetes? * Our weight loss plans will vary depending upon your diabetes treatment(s) I have diabetes and take medications for it I have diabetes and it is diet controlled No, but my family have diabetes I am pre-diabetic I am NOT diabetic Do you suffer from any of the following? * These conditions can lead to serious complications when losing weight or taking weight loss medications. Please tick all that apply Chronic malabsorption syndromes (problems absorbing food) Cholestasis Currently being treated for cancer Diabetic retinopathy Severe heart failure Family history of thyroid cancer or had thyroid cancer History of pancreatitis End stage kidney disease Eating disorder such as bulimia, anorexia nervosa, binge eating Previous bariatric surgery None of the above Do you suffer from any of the following conditions? * These conditions may improve with weight loss. Please tick all that apply Depression and/or anxiety Social anxiety Joint pains / aches Osteoarthritis GORD / indigestion Heart / cardiovascular problems High blood pressure including family history Fatty liver disease Sleep apnoea COPD Erectile dysfunction Low testosterone Menopausal symptoms Polycystic ovary syndrome None of the above Do you have any other medical conditions? Have you tried any of the following medications to you help lose weight? Please tick all that apply Alli Mounjaro Mysimba Ozempic Rybelsus Saxenda Wegovy Other None of the above Do you currently take any of these medications? * Levothyroxine Warfarin None of the above Do you take any other medications? Including any prescribed; over the counter; health supplements or herbal products etc. Do you have any allergies? Would you like your GP to be informed of this consultation? * To ensure we provide the best and safest service for you, we strongly encourage you to share your GP details so we can inform them about your treatment. If you are aware of your GP practice's email address, please enter below. Yes No GP details Include name, address and Doctor's name How did you hear about us? Which medicine would you like to be considered for? Alli Mounjaro Saxenda Wegovy Not Sure Thank you for contacting Pharmacy Cube. A Specialist Pharmacist will review your information and contact you within 24 hours to confirm your booking.Pharmacy Cube1A Kingsley Gardens,London, E4 8JS0203 662 0722Info@pharmacycube.co.uk