| Case Status | Awaiting Payment |
|---|---|
| Select Practitioner | otikrity@hotmail.com |
| 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 | Test Test |
| Phone | 07949751224 |
| Address | 79 Bolshaw Road Heald Green SK8 3PD Map It |
| Date of Birth | 04/04/1995 |
| Age | 31 |
| Gender | Male |
| 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) | 150 |
| Weight (kg) | 90 |
| Your BMI | 40 |
| Your BMI | 0 |
| What is your usual blood pressure range? | Low - 90/60 or Below |
| What is your ethnicity? | Asian or Asian British - Includes any Asian background, for example, Bangladeshi, Chinese, Indian or Japanese. |
| 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 |
| 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 | GP Test |
| GP Address | GP Test Address |
| GP Phone Number | 01612259646 |
| 3. About Your Lifestyle | Providing accurate details about your lifestyle helps us tailor a plan that fits your habits and goals. |
| Do you smoke? | No |
| Do you drink alcohol? | No |
| Bottle of lager/beer/cider (5%) 330ml | 0 |
| 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? | Very little |
| 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? | Less than 1000 |
| Please describe your typical daily diet: | Test daily diet |
| 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? | No |
| 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 |
| Consultation DateTime | 2026-05-17 12:30 |
| Consultation Join URL | https://zoom.us/j/91065693808?pwd=X0srBoQxLMtTx7xRAkR0mwBeG1bTm3.1 |