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Home
About
Services
Pain Management & Sleep Therapy
Sexual Health
Mental Health
Nicotine Replacement Therapy
Skin Health
Hair Loss
Weight Management
Repeat Prescriptions
Telehealth Services
Hormone Therapy
Doctors
Blog
Contact
Home
About
Services
Pain Management & Sleep Therapy
Sexual Health
Mental Health
Nicotine Replacement Therapy
Skin Health
Hair Loss
Weight Management
Repeat Prescriptions
Telehealth Services
Hormone Therapy
Doctors
Blog
Contact
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Weight Loss Questionnaire Form
First Name
*
Last Name
*
Phone
Email Address
*
What is your date of birth?
*
What was your sex at birth?
*
Male
Female
Are you currently pregnant or breastfeeding, or is there a chance that you may be pregnant?
*
Yes
No
What is your ethnic background?
*
Aboriginal or Torres Strait Islander
Asian
Middle Eastern
Latino/Hispanic
Caucasian
Pacific Islander or Maori
African
Not Listed
What is your height in centimetres?
*
What is your weight in kilograms?
*
What is your current waist size (in inches)
*
(This is usually the same number as your pant size)
Have you ever tried losing weight before?
*
Yes
No
Lifestyle
Do you smoke?
*
No
Yes
Rarely
How long have you been smoking for and how many cigarettes per day?
*
Do you use any recreational drugs?
*
No
Yes
What recreational drugs do you use?
*
How often do you drink alcohol?
*
Not at all
Rarely
Less than two standard drinks per day
More than two standard drinks per day
How often do you exercise?
*
3-5 times per week
2-3 times per week
Once a week
Not a priority
How would you describe your diet?
*
Very healthy
Healthy
Average
Poor
How many times a week do you eat out or get take away/ home delivery?
*
0-1 times a week
2-3 times a week
4-5 times a week
Every day
How often do you snack?
*
0-1 times a day
2-3 times a day
4-5 times a day
Do not
How many times do you eat processed food per week?
*
0-1 times per week
2-3 times per week
4-5 times per week
Every day
Multiple times per day
How often do you eat fruit or vegetables?
*
Every day
Now and then
Rarely
What about soft drinks (excluding zero cal or sugar free drinks)?
*
0-1 times per week
2-3 times per week
4-5 times per week
Every day
Multiple times per day
How would you rate your average nights' sleep?
*
0
1
2
3
4
5
(5 stars = Excellent 1 star = Very bad)
How would you rate your mood recently?
*
0
1
2
3
4
5
(5 stars = Excellent 1 star = Very bad)
How would you rate your physical fitness
*
Excellent
Good
OK
Below average
Poor
Does your weight interfere with your ability to exercise?
*
No
Yes
Hard to say
Medication History
Do you have any allergies?
*
Yes
No
What allergies do you have?
*
What weight loss methods have you tried?
*
Diets
Gym/Exercise
Fasting
Doctor/Prescription
Surgery
Dietitian
Meal Replacement Shakes
Other Health Care Provider
Please select all that apply.
Which prescriptions have you tried?
*
Semaglutide (Also known as Ozempic)
Liraglutide (Also known as Saxenda)
Tirzepatide (Also known as Mounjaro)
Naltrexone/Bupropion (Also known as Contrave)
Something else
Please select all that apply.
What was the dose of this medication and when was the last dose administered?
*
How long has it been since you were your ideal weight?*
*
Less than 1 year
1-3 years
4-5 years
>5 years
Never
What supplements do you currently use?
*
Are you currently taking any of the below medications?
*
Anti-inflammatory medications
Heart medications
Fluid-reducing medications or diuretics
Insulin
Blood pressure medications
Lithium
Anti-diabetic medication
Anti-depressant or anti-anxiety medication
Oral contraceptive pill
No, I am not taking any of the above medication
Medical Conditions
Have you ever had any issues with the following?
*
Abnormal liver function
Gallstones or other gallbladder problems
Kidney disease / reduced kidney function
Diabetic retinopathy / Diabetic eye disease
Pancreatitis or other pancreas issues
Low blood sugar (hypoglycaemia)
Thyroid tumors
History of significant mood disorder or suicidal thoughts
No, I haven't been diagnosed with any of these conditions
Please give the doctor more information.
*
Just to be in case, have you ever had any issues with the following?
*
High blood pressure (hypertension)
Obstructive sleep apnoea
Heart disease or any other peripheral vascular disease
Gastrointestinal problems (e.g. reflux, fatty liver)
Hormonal or sexual dysfunction (e.g. erectile dysfunction, irregular periods, reduced libido)
High cholesterol or high triglycerides (blood fats)
Osteoarthritis or weight-related joint pain
Palpitations or abnormal heart rhythm
Urinary problems (e.g. incontinence)
High blood sugar (hyperglycaemia)
No, I haven't been diagnosed with any of these conditions
Have you in the past, or do you currently suffer from any mental disorders?
*
Anxiety
Bipolar
Depression
Psychotic disorder
Other
None
(Please select all that apply.)
Do any of the following apply to you?
*
Cancer
Kidney problems
Liver problems
Lung or pulmonary problems
Nerve or neurological problems
Using hormones or steroids
None
Have you had any of the following surgeries?
*
Lap-band
Sleeve gastrectomy
Roux-en-y gastric bypass
Gastric balloon
None of the above
Do you ever make yourself sick (vomit) because you feel uncomfortable full or worried you have overeaten
*
Yes
No
Family History
Is there a history of any other medical illness or disorder that has run within your family?
*
Yes
No
Please explain the medical illness that has run within your family.
*
(Note: Would you like to add any other information that you find might be helpful to share with your doctor?)
Submit
