| Case Status | Consultation Complete |
|---|---|
| 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 | Magdalena Krzyzowska |
| Phone | 07463834404 |
| Address | 50 Glendinning Terrace Galashiels TD1 2JW Map It |
| Date of Birth | 16/06/1983 |
| Age | 43 |
| 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) | 167 |
| Weight (kg) | 102 |
| Your BMI | 36.57 |
| Your BMI | 0 |
| What is your usual blood pressure range? | High - 140/90 or Above |
| 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 |
| Do you suffer from any liver problems? | Yes |
| Please give details: | fat liver mild, advised diet, reversible, no alcohol, not smoking |
| 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? | Yes |
| Please give details: | mild depression |
| Do you suffer with an eating disorder? | No |
| Do you have any other medical problems? | Yes |
| Please give details: | gallbladder removal 7 years ago |
| Are you taking any other medication not already identified above? | No |
| Do you have any known allergies? | No |
| GP Name | Braeside Medical Practice |
| GP Address | curry road Galashiels |
| GP Phone Number | not known |
| 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 |
| How many cups of tea or coffee do you drink each day? | 3-4 |
| How many glasses of water do you drink each day? | 3-4 |
| How many hours of sleep do you get on average each night? | Less than 4 |
| 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? | 2001 - 2500 |
| Please describe your typical daily diet: | normal |
| What contributes to your excess weight? (Please tick ALL that apply) |
|
| Please describe: | eating at night |
| Please tell us what weight loss interventions you have previously tried: | different diets |
| 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 |