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Injectable Questions

Medical Assessment

Answer a few quick and easy questions from our pharmacists to see what treatments you’re eligible for.

Weight Assessment

Please ensure you enter accurate height and weight details as this may affect future prescribing decisions

Enter Your Height:

CM Feet/Inches

Enter Your Weight:

KG Stone Pounds

Have you been diagnosed with any conditions such as:

Pre-diabetes
Type 2 diabetes
Hypertension
Heart disease
Hypercholesterolaemia (High cholesterol)
Obstructive sleep apnoea

Yes No

Your Health

Are you between the ages of 18-75?

Yes No

Are you pregnant, planning to become pregnant, or breastfeeding?

Yes No

Are you aware of the differences in the injectable treatments that we offer:

Wegovy is a once-a-week injection that works by reducing your appetite
Mounjaro is a once-a-week injection that works by reducing your appetite
Saxenda is a daily injection that works by reducing your appetite

Yes No

Do you have any known allergies or hypersensitivity to any GLP-1 agonists such as liraglutide, semaglutide, tirzepatide, or any of the other ingredients in these injections?

Yes No

Have you ever been diagnosed with an eating disorder such as Anorexia Nervosa or Bulimia?

Yes No

Medical Conditions

Do you have any other medical conditions?

Yes No

Do you have any of the following conditions:

Hepatic (liver) impairment
Renal (kidney) impairment
Chronic malabsorption syndrome
Inflamed gallbladder or gallstones
Inflammatory bowel disease (IBD)
Congestive heart failure
Diabetic gastroparesis
Diabetic retinopathy
A history of pancreatitis (inflammation of the pancreas)
Severe depression or suicidal thoughts

Yes No

Do you have a personal or family history of any thyroid cancers or an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?

Yes No

Medication

Are you taking any of the following medications:

Insulin
Insulin secretagogues, such as sulfonylureas (gliclazide)
Warfarin or other anti-coagulants
Other products for weight management
Other GLP-1 agonists

Yes No

Are you taking levothyroxine or liothyronine for underactive thyroid?

Yes No

Is this the first time you will be using any of these injectable weight loss treatments?

Yes No

Which of the injectable weight loss treatments have you used:

Saxenda

Wegovy

Mounjaro

Ozempic

None of the above

When did you last use an injectable weight loss treatment:

Within the last 4 weeks

Between 4-8 weeks ago

More than 8 weeks ago

Have you experienced any serious side effects whilst using the injectable weight loss treatment?

Yes No

Agreement

Do you understand that you will be asked to provide proof of treatment from an alternative provider if:

This is your first order with us and you have selected a higher dose than the starting dose
You have selected a higher dose and your last order from us was more than 8 weeks ago

Yes No

Do you understand that this medication must only be used in combination with a reduced-calorie diet and increased physical activity? It is advised to be on a mildly hypocaloric diet that contains approximately 30% of calories from fat. It is recommended that the diet is rich in fruit and vegetables.

Yes No

Do you understand that when starting treatment, you may lose body fluid or become dehydrated? Signs of this include nausea, vomiting and diarrhoea. It is important to drink plenty of fluids to keep yourself hydrated during this treatment

Yes No

Do you understand that this medication should be discontinued if your BMI goes below 27kg/m2?

Yes No

Are you aware that use of GLP-1 receptor agonists can be rarely associated with acute pancreatitis? If symptoms of acute pancreatitis develop, such as severe stomach pain that may spread to the back or chest, nausea, vomiting, and a rapid heartbeat, please discontinue treatment and seek medical help.

Yes No

Are you aware these injections in rare cases can be associated with cholelithiasis and cholecystitis? If symptoms of these develop, such as severe pain in the upper abdomen that may spread to between the shoulder blades, nausea, vomiting, jaundice, fever and bloated belly, discontinue treatment and seek medical help

Yes No

Do you understand that female patients of child-bearing age administering GLP-1 receptor agonists such as Mounjaro, Wegovy and Saxenda, should use adequate contraceptive methods whilst on this treatment?

Yes No

Do you agree to the following:

You will read the patient information leaflet before using this medication
You are aged 18 years or over
You have answered all questions truthfully and accurately
You understand that we take your answers in good faith and any false or incorrect information given can be hazardous to your health
This treatment is solely for your own use
You will contact us and inform your GP if you experience any side effects with your treatment, you start any new medication/your medical conditions change during treatment
You will inform your GP of this treatment if this is appropriate

Yes No

GP Details

In compliance with regulations, we must notify your GP about this treatment. To do so, we need their contact information. Sharing this information allows your GP to maintain a comprehensive record of your medical history, which is crucial for your health. Without complete records, there could be potential risks to your well-being.

I consent to YourMedicals contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Complete our 2 minute questionnaire

Confidential

Our prescribers will carefully review your information with full confidentiality.
Your medication will be delivered in plain, unmarked packaging
All data is securely encrypted using 128-bit SSL encryption.

Need help?

If you require assistance with this medical assessment, please reach out to our support team:: 0116 507 0486

Your weight loss treatment

Injectable weight loss medication helps reduce the body's absorption of dietary fat, leading to lower calorie intake. It's commonly used alongside a reduced-calorie diet and exercise program.

Mounjaro

Wegovy