signs of skin ageing– Page 3– Essentials London / Pharmacy & Clinic

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Essentials London, Pharmacy and Clinic, 169 Drury lane, Covent Garden, WC2B 5QA
020 7404 8808
Shop@essentialslondon.com

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Weight loss isn’t one size fits all

⁠We’ll now ask you a few questions to assess your eligibility and personalise your treatment.

⁠⁠Your responses will be kept private and confidential.

Do you agree and consent to the following (Required)

I am over 18 years old and live in the UK.
I will be the sole user of any medication offered to me through this service.
I confirm all answers are provided by me, and are completely truthful.

Yes

Name (Required)

First

Last

Date Of Birth (Required)

Gender (Required)

Current Weight (in Kg) (Required)

Unit

Height (in cm)(Required)

Unit

Contact Information

Email (Required)

Phone (Required)

Medical History

Do you have any of the following chronic health conditions? (Required)

Diabetes (Type 1 or Type 2)

Cardiovascular Disease

Thyroid Disorders

Gastrointestinal Disorders (e.g., IBS)

Liver or Kidney Disease

Pancreatitis or history of pancreatitis

Other chronic health conditions (Please specify)

None of the above

Please specify (Required)

Do you have a history of any of the following? (Required)

Allergies to medications

Gallbladder Disease

Cancer or a family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia Syndrome type 2 (MEN 2)

Mental health conditions (e.g., depression, anxiety, eating disorders)

Hepatic impairment

Rebal impairment

Heart failure

Inflammatory bowel disease

Diabetic gastroparesis

Other significant medical conditions (Please specify)

None of the above

Please specify (Required)

Are you currently pregnant, planning to become pregnant, or breastfeeding? (Required)

Yes

Please be aware (Required)

These medications are not suitable in pregnancy or if you are trying to conceive.
If you are sexually active, we advise contraception when taking this medication.
This should be a non-oral contraception (e.g. condoms or the coil) if using Mounjaro or Orlistat.
If you're taking oral contraceptives, you will need to take an additional form of contraception during treatment, due to reduced absorption which can result in oral contraceptives being ineffective.

I Understand

I don’t wish to continue

Current Medications and Supplements

Please list all medications you are currently taking, including over-the-counter medications and supplements. (Optional)

Have you previously used any weight loss medications or treatments? If so, please specify which ones and your experience with them. (Required)

Yes

Please specify (Required)

Are you currently taking any other GLP-1 receptor agonists (e.g., semaglutide) or insulin? (Required)

Yes

Which product and doeses are you using now: (Required)

Wegovey 0.25

Wegovey 0.5

Wegovey 1

Wegovey 1.7

Wegovey 2.4

Wegovey 2.5

Mounjaro 5

Mounjaro 7.5

Mounjaro 10

Mounjaro 12.5

Mounjaro 15

None of the above

Have you previously tried any of the following methods to lose weight? (Required)

Diet and Nutrition Plans (e.g., calorie counting, low-carb, keto, etc)

Exercise Programs

Surgical Options (e.g., gastric bypass, lap band)

Other weight-loss methods (please specify)

None of the above

Please specify (Required)

What is your primary goal with Mounjaro/Wegovy? (Required)

Weight Loss Only

Other (please specify)

None of the above

Please specify (Required)

Dietary and Exercise Habits

How would you describe your current diet? (Required)

Balanced

High in Processed Foods or Sugar

Low Carb or Keto

Vegetarian or Vegan

Other (please specify)

None of the above

Please specify (Required)

Do you currently exercise? (Required)

Yes (If yes, please specify the type and frequency.)

Please specify (Required)

How many meals do you usually eat in a day?

On average, how much water do you drink per day?

Risk Assessment

Do you have a family history of thyroid cancer, pancreatitis, or MEN2 syndrome? (Required)

Yes (If yes, please specify the type and frequency.)

Please specify (Required)

Do you currently experience any of the following symptoms? (Required)

Persistent nausea or vomiting

Abdominal pain

Difficulty swallowing or breathing

Any other gastrointestinal symptoms (please specify)

None of the above

Please specify (Required)

Expectations and Goals: What are your primary motivations for starting Mounjaro/Wegovy? (Required)

Health Improvement

Aesthetic or Physical Appearance

Energy and Vitality

Managing a chronic condition

Other (please specify)

None of the above

Please specify (Required)

Are there specific goals you would like to achieve within a set timeframe? If so, please list them

Required

Tell us if your currently experiencing any dieases symptoms