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Saxenda: New Patient Details Form.
A brief summary of basic patient information.
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* Indicates required question
Email
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Your email
Full Name
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Your answer
Date of birth
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MM
/
DD
/
YYYY
Home address
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Your answer
Phone number
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Your answer
I consent to undertaking a remote consultation about my weight loss aims and would like to use Saxenda. I understand that I am obliged to give full and truthful answers and that failure to do so may result in sub-optimal medical care.
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Yes
No
What is your weight in kilograms?
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Your answer
What is your height in metres?
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Your answer
What is your Body Mass Index (BMI)?
Your answer
What was your last blood pressure reading and when was it recorded?
Your answer
Please list any other weight management or weight loss drugs that you are currently taking or intend to take.
Your answer
How have you tried to lose weight before? What have been your main struggles with this?
Your answer
Are you pregnant, planning pregnancy or is there a possibility you may be pregnant?
Yes
No
Clear selection
Are you currently breast-feeding?
Yes
No
Clear selection
Do you have a history of any of the following conditions?
Diabetes
Ketoacidosis.
Diabetic gastroparesis.
Inflammatory bowel disease (Crohn's/UC)
Congestive heart failure.
Obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain.
Severe kidney impairment.
Severe liver impairment.
Pancreatitis.
Clear selection
Do you or have you ever had an eating disorder? Please give details.
Your answer
Please list any other long-term medical conditions that you suffer from?
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Your answer
Lists the names and doses of any medicines or supplements you take regularly.
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Your answer
List any allergies that you suffer from.
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Your answer
Do you smoke? If so, how many cigarettes a day?
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Your answer
How many units of alcohol do you drink each week
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Your answer
I have received information on the risks and benefits of Saxenda treatment through the website
DoctorBrad.co.uk
, and I have no further questions at this time. I have read the recommended patient brochures and information leaflets linked from
https://www.doctorbrad.co.uk/saxenda-online
. I understand that Dr Bradley Tomkins is available to remotely answer additional questions about this treatment, as required. The medical information I have provided is true and accurate to the best of my knowledge and I consent to the treatment being given. I understand that Dr Bradley Tomkins will review my form to determine my suitability for Saxenda before issuing further instructions.
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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