Assessment Form
Fill in this form and we can see if you're able to use Saxenda.
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Email *
Name *
Address *
Date of birth *
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Phone Number
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Do you consent to being contacted about your responses? *
GP Practice (Optional)
Would you like your GP to be contacted about the outcomes of this assessment?
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List any medical conditions you have *
Please list any medications you take, including prescribed and over the counter *
Do you smoke? *
Has a low calorie diet previously failed to control your weight? *
Do you have or have you ever had pancreatitis? *
Do you have or have you ever had gallstones? *
Have you ever had an adverse reaction to liraglutide (Saxenda/Victoza)? *
Are you pregnant or breast feeding? *
Is there any chance you are pregnant or are you planning a pregnancy? *
Do you have any of the following listed below? High or low blood sugar; high blood pressure; raised fat or cholesterol levels in the blood;̵ Obstructive sleep apnoea. *
Do you have or have you ever had any eating disorders? *
Would you object to a low-calorie diet as part of treatment? *
Do you have any liver, kidney or heart problems? Please give details
Do you have any allergies? Please give details *
Are you currently using any weight management products? Please give details *
Do you have any recent or past medical history of note (i.e. other medical conditions that you have previously been treated for or are currently receiving treatment for)? *
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