Weight loss consultation

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Important notice. To comply with recent regulations introduced by the GPhC, all successful weight loss will need to have a follow up video consultation before orders are dispatched. There is no extra charge for these consultations.

Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

What are your primary motivations for wanting to lose weight? *

Enhancing my overall health
Preventing or managing a specific health condition
Boosting my appearance and self-confidence
Increasing my physical activity
Elevating my mood or mental wellbeing
Improving my sleep or energy levels
Other

Please tell us what is your motivation for losing weight *

What is your height in cm *

What is your weight in kg *

Do you have a specific target weight you aim to reach? *

What is your target weight *

Have you ever been diagnosed with an eating disorder such as anorexia or bulimia? *

We’re sorry, but there are no suitable treatments for you.

The safety and well-being of our patients is our number one priority, and based on your answers, we can’t recommend any of our treatment options. We know this is both frustrating and disappointing, but we want to make sure that we’re putting your health first and that you find the right care.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

How long have you been dealing with weight issues? *

For the past 12 months
For the past 5 years
For the past 10 years
Most of my life

What methods have you previously used to try to lose weight? *

Exercise or increased activity
Dieting
Calorie counting
Weight loss programs
Weight loss supplements
Meal replacements and shakes
Other methods
I haven’t tried to lose weight

What other methods of weight loss have you tried? *

What challenges have you faced with exercise or trying to be more active? *

I do not have enough time
I lose motivation
Injury/illness makes it difficult
I do not find it enjoyable
I feel uncomfortable exercising in front of others
I haven’t tried to be more active
Other

What other challenges have you faced when trying to lose weight *

What difficulties have you encountered while trying to change your eating habits? *

I get hungry
I experience cravings
I snack frequently
I overeat when I’m stressed
I alternate between being disciplined and binge eating
I’m unsure of what I should be eating
Other

What other difficulties have you faced when trying to change your eating habits? *

What obstacles have you encountered while trying to maintain your weight loss progress? *

I lose motivation
I struggle with consistency
I don’t have enough time
I lose weight but then regain it
Other

What other obstacles have you encountered? *

Do you suffer from any of the following?

Severe liver or kidney impairment
Heart failure
History of pancreatitis
Multiple endocrine neoplasia type 2
Active cancer
Type I diabetes or diabetic retinopathy
Personal or family history of medullary thyroid cancer
Do you currently have or have you previously had an eating disorder? (e.g., anorexia, bulimia, binge eating disorder)
History of gallbladder problem
History of inflammatory bowel disease or delayed stomach emptying (gastroparesis)

Medical condition red flag *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Which of the following do you suffer from? *

Type 2 diabetes
High blood pressure
High cholesterol
Erectile dysfunction
Sleep apnoea
Asthma
Osteoarthritis
Chronic back pain
Depression
PCOS
Fatty liver disease
None of the above

Some of our medications, including Mounjaro, can reduce blood sugar levels when combined with other diabetes treatments. Signs of low blood sugar may include shaking, sweating, dizziness, intense hunger, and confusion. If you experience any of these symptoms, please seek medical attention immediately.

Hypo understanding *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you taking any of the following medications?

Insulin
Sulfonylureas, e.g. gliclazide

Medicine Red Flag *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you currently take any of the following medications? *

Levothyroxine
Oral medications for diabetes
Warfarin
None of these

Taking weight loss injections can mean that over time you may need to adjust the dose of this medication. Do you agree to continue to see your own doctor for monitoring of your thyroid function and to follow the dose adjustments that your doctor recommends?

Select one answer

Levothyroxine warning *

I agree
I do not agree

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Please upload a full-body side profile photo

To be accepted by our clinical team, your photo must:

Clearly show you from head to toe
Include your face
Be in tight-fitting clothing to show your body shape
Be taken in the last 7 days

Upload photo *

Click or drag a file to this area to upload.

What is your biological sex? *

Male
Female

Are you pregnant, breastfeeding, or trying for a baby? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you currently use oral contraception? *

There is some evidence that these medications can reduce the efficacy of the oral contraceptive pill. Are you happy that you will use a non-oral contraceptive method, or add a barrier method of contraception upon initiating therapy (for 4 weeks), or after each dose escalation (for 4 weeks).

Contraceptives warning *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any other medical conditions not already mentioned? *

Please provide more details *

Are you taking any other medications that have not already mentioned? *

Please provide details of any other medical conditions you have or any medications you are currently taking. Please include the name of the medication, dosage, and how long you have been taking it. Provide all details you think would be relevant for our clinicians to know.

Other medication *

Do you have any allergies? *

Please give us more details on these allergies *

Do you agree and consent to the following?

I am at least 18 years old and live in the UK.
I have the capacity to make decisions about your own healthcare
I shall be the sole user of any medication offered to me through this service.
I confirm all answers are provided by me and are truthful.
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
If prescribed a treatment, I will read the Patient Information Leaflet (PIL) that will be provided.
If prescribed a treatment, I will inform my GP of my treatment and contact them if I have any side effects associated with the treatment.
You agree to our terms and conditions, privacy policy and acceptable use policy
You are aware you will be subject to a soft check to validate your identity using LexisNexis.

Checkboxes *

I agree to the statements and give my consent for any treatment provided.

Are you registered with a GP in the UK?

(Optional) Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

Summary care records

I consent

(Optional) Do you give us consent to write to your GP to share information of this supply and any information we hold about you?

Send information to GP

I consent

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Important

We review all orders to ensure they’re the best treatment we can offer you. If what you ordered is unsuitable, we will refund part or all of your order.

If we decide what you ordered is unsafe for you, given the other information you provided, we won’t issue any treatment. However, we may call you and suggest alternatives.

Weight loss consultation

Important notice. To comply with recent regulations introduced by the GPhC, all successful weight loss will need to have a follow up video consultation before orders are dispatched. There is no extra charge for these consultations.

There is some evidence that these medications can reduce the efficacy of the oral contraceptive pill. Are you happy that you will use a non-oral contraceptive method, or add a barrier method of contraception upon initiating therapy (for 4 weeks), or after each dose escalation (for 4 weeks).

Do you agree and consent to the following?

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Treatments

Care and policies