SW Pharma - Medical Assesment

Personal Details

This assessment is an important part of your weight loss consultation.Please answer all questions truthfully, including details about any medications you're currently taking. This helps our doctors recommend the most suitable treatment.

First Name *

Last Name *

Email *

Address *

City/Town *

Post Code *

Date of Birth *

Sex at Birth *

Phone Number *

GP Details

GP Practice Name *

GP Practice Address *

GP Name *

Telephone Number *

GP Practice Email*

Weight Assessment

Please ensure you enter accurate height and weight details as this may affect future prescribing decisions.

Enter Your Height

CM Feet/Inches

Enter Your Weight

KG Stone Pounds

You are not eligible for this because your BMI is less than 30.

What is your ethnicity?

This information helps our prescribers better assess any weight-related health risks and provide personalised care.

Your Health

Do you have any of the following conditions?

Type 1 diabetes

Inflammatory bowel disease (IBD) such as Crohn’s disease or Ulcerative colitis

Pancreatitis (current or previous issues)

Diabetic retinopathy

Diabetic Gastroparesis

Gallbladder or bile duct issues

History of severe liver or kidney disease

History or family history of thyroid cancer, medullary thyroid cancer or MEN 2

Any cancer, current chemotherapy or radiotherapy

Gastric (bariatric) surgery in last 12 months

None of the above

Your Health

Please let us know if you have any of the following conditions:

Type 2 diabetes

Pre-diabetes

Hypertension (high blood pressure)

Heart disease (e.g. heart attack, atrial fibrillation)

High cholesterol

Fatty Liver disease

Obstructive sleep apnoea (OSA)

Polycystic ovary syndrome (PCOS)

Gastroesophageal reflux disease (GORD)

Irritable bowel syndrome (IBS)

None of the above

Screening for Contraindications

Are you pregnant, planning to become pregnant, or breastfeeding? *

Yes No

Do you have any known allergies or hypersensitivity to any GLP-1 agonists such as semaglutide (Wegovy), tirzepatide (Mounjaro), or any of the other ingredients in these injections?*

Yes No

Have you ever been diagnosed with an eating disorder? *

Anorexia Nervosa

Bulimia

None of the above

Medication

Are you taking any of the following medications*

Insulin

Other Antidiabetics (e.g. metformin, gliclazide, empagliflozin, dapagliflozin, canagliflozin)

Warfarin or other anti-coagulants

Digoxin

Lithium

Other products for weight management

Other GLP-1 agonists (e.g, Ozempic, Saxenda®, Wegovy®, Mounjaro®)

None of the above

Any over-the-counter medications, herbal remedies or dietary supplements?*

Yes No

Please Provide Further Details

Are you currently using any of the following (You have used a dose within the last 2 weeks) *

Wegovy

Ozempic

Mounjaro

Xenical/Orlistat

Other

I'm not currently taking anything

Proof of Prior Treatment Required

As you have used a GLP-1 medication (e.g. Wegovy, Saxenda, or Mounjaro) within the last 2 weeks, please upload proof of treatment from an alternative provider.:*

Accepted forms of evidence include:

A copy of a prescription
A photo of the medication box with the dispensing label

Ensure your evidence includes *

Your Name
Medication Details
Prescription Date

Upload Evidence * (Accepted: JPG, PNG, PDF) Only JPG, PNG, or PDF files are allowed.

Do you understand that this treatment must only be used in combination with a reduced-calorie diet and increased physical activity? It is advised to be on a mildly hypocaloric diet that contains approximately 30% of calories from fat. It is recommended that the diet is rich in fruit and vegetables.*

Yes

Do you understand that when starting treatment, you may lose body fluid or become dehydrated? Signs of this include nausea, vomiting and diarrhoea. It is important to drink plenty of fluids to keep yourself hydrated during this treatment*

Yes

Do you understand that this treatment should be discontinued if your BMI goes below 23.5kg/m2? If your BMI falls below this, it may no longer be appropriate or safe to continue treatment. Please speak to a healthcare professional before continuing with your treatment.*

Yes

Are you aware that GLP-1 medications can, in rare cases, be associated with acute pancreatitis?*

If you develop any of the following symptoms, you should stop the medication and seek urgent medical attention:

Sudden, severe stomach pain (which may spread to the back or chest)
Tenderness or swelling of the tummy
Nausea or vomiting
A fast heartbeat or rapid breathing
Fever of 38C or more

Yes

Contraception Required During Treatment

GLP-1 medications such as Mounjaro and Wegovy, are not recommended during pregnancy, as their safety has not been established. If you are of child-bearing age, you must use effective contraception while taking this medication to prevent potential harm to an unborn baby. Please ensure you understand this requirement before proceeding. If you have any questions,speak to a healthcare professional for guidance.*

Yes

Patient Agreement

Please read each section carefully and confirm your understanding:

Personal Responsibility

I confirm the information I’ve provided is accurate. I understand that providing false or misleading information may harm my health.
I will read the Patient Information Leaflet before starting treatment.
I confirm this treatment is for my personal use and I consent to receiving it.
I will update SW Pharma and/or my GP if my health, medical conditions, or medications change.
I know I can contact SW Pharma, my GP, or another healthcare professional if I have side effects.

Treatment Use & Administration

I understand only one weight loss medication should be used at a time.
I will follow the correct dose escalation schedule for safety and effectiveness.
If I miss more than 2 weeks of treatment, I may need to restart on a lower dose.
I understand that Wegovy/Mounjaro is given as a subcutaneous injection (under the skin), not into a vein or muscle. I will inject into the stomach, upper thigh, or upper arm.
I will stay hydrated throughout treatment.
If the treatment is not effective, I will consult my GP for further advice.

Additional Information for Female Patients

I understand that I must use reliable contraception throughout treatment (and for at least 2 months after stopping Wegovy).
I will stop Wegovy at least 8 weeks and Mounjaro at least 4 weeks before trying to conceive.
If using oral hormonal contraception with Mounjaro, I will also use a barrier method (e.g. condoms) for 4 weeks after starting or increasing the dose.
I will stop treatment and contact my GP immediately if I become pregnant.

Delivery & Agreement

I understand that orders placed after 12pm on Friday (excluding public holidays) will be dispatched on Monday, due to cold chain delivery requirements.
I agree to the terms and conditions of SW Pharma and Health Finder Pro.

Final Confirmation

I confirm I understand and agree to all the above statements.

I acknowledge that my BMI must be verified before a prescription can be issued, in line with updated GPhC guidance.

I consent for the outcome of my consultation to be sent to my GP surgery for continuity of care. (Read consent details)

Menu

Medical Assessment

Personal Details

GP Details

Weight Assessment

What is your ethnicity?

Your Health

Your Health

Screening for Contraindications

Medication

Proof of Prior Treatment Required

Contraception Required During Treatment

Patient Agreement

Personal Responsibility

Treatment Use & Administration

Additional Information for Female Patients

Delivery & Agreement

Final Confirmation

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