| Case Status | Dispensed |
|---|---|
| Select Practitioner | anna@directweightloss.co.uk |
| 1. About You | Please ensure all information is accurate and complete to help us personalise your weight loss plan. |
| Email hidden; Javascript is required. | |
| Name | Karen Fenech |
| Phone | 07904878540 |
| Address | Parkside Buccleuch Road Hawick . Hawick td9 0el Map It |
| Date of Birth | 02/04/1991 |
| Age | 45 |
| Gender | Female |
| Are you pregnant, breastfeeding or trying to get pregnant? | No |
| We need to calculate your BMI. Please choose preferred measurement type. | I will measure in cm/kg |
| Height (cm) | 160 |
| Weight (kg) | 85 |
| Your BMI | 33.2 |
| Your BMI | 0 |
| What is your usual blood pressure range? | Normal - Between 91/41 and 139/89 |
| What is your ethnicity? | White - Includes any White background, for example, British or Irish traveller. |
| Do you suffer from any heart problems? | No |
| 2. About Your Health | It’s essential that you provide your correct medical history. Honesty is crucial to ensure your safety throughout the programme. |
| Do you have any thyroid problems? | No |
| Have you, or anyone in your immediate family, ever had thyroid cancer? | No |
| Do you currently, or have you ever had pancreatitis? | No |
| Please give details: | kidney stones |
| Do you suffer from any liver problems? | No |
| Do you suffer from any SEVERE gastro-intestinal problems? | No |
| Do you suffer with diabetes? | No |
| Are you taking Insulin? | No |
| Do you suffer from any mental health problems? | No |
| Do you suffer with an eating disorder? | No |
| Do you have any other medical problems? | No |
| Are you taking any other medication not already identified above? | No |
| Do you have any known allergies? | No |
| GP Name | kirk |
| GP Address | Unit 17 |
| GP Phone Number | 01450363352 |
| 3. About Your Lifestyle | Providing accurate details about your lifestyle helps us tailor a plan that fits your habits and goals. |
| Do you smoke? | Yes |
| How many per day? | 1-5 |
| Do you drink alcohol? | Yes |
| How many units per week? | 6-10 |
| Bottle of lager/beer/cider (5%) 330ml | 4 |
| How many cups of tea or coffee do you drink each day? | 1-2 |
| How many glasses of water do you drink each day? | 1-2 |
| How many hours of sleep do you get on average each night? | 7-8 |
| How many exercise/activity do you do each week? | 1 Hour |
| 4) Your Weight Loss Journey | Tell us about your past and current efforts to lose weight so we can better understand your journey and provide the right support. |
| How many calories do you consume per day? | 1000 - 1500 |
| What contributes to your excess weight? (Please tick ALL that apply) |
|
| Please tell us what weight loss interventions you have previously tried: | none |
| Are you currently taking any weight loss treatments such as Mysimba, Saxenda, Wegovy, Ozempic or Phentermine? | Yes |
| Which one, and how long have you been taking it? | Wegovy 1mg |
| Patient Signature | |
| 6) Proof of ID | To complete your application, please upload a clear photo copy of your passport photo page or driving licence. Your full name and date of birth must be clearly visible. This helps us verify your identity and ensure that any treatment provided is safe, appropriate, and legally compliant. |
| Upload Copy of Your ID | |
| Internal use | |
| Clinical Decision | Approved |