Consultation - Everslim

1 Let's Get Going!

Welcome to Everslim! To ensure that the treatments we supply are suitable for you, please answer this short questionnaire. Should you require assistance completing this form, then please contact a member of our Patient Care Team.

Do you agree with the following?

1. You are between the ages of 18yrs to 75yrs and live in the United Kingdom.

2. You affirm that you are completing this consultation on your own behalf and are providing information to the best of your knowledge and ability.

3. You confirm that this treatment is solely for your own use and commit to utilising only one weight loss treatment concurrently.

4. You agree to read the Patient Information Leaflet supplied with the medication (if prescribed) and confirm that you are aware of the possible side effects of the medication.

5. You agree to a soft check to validate your identity via Lexis Nexis Identification Validation.

6. You commit to fully disclosing any medical conditions, significant illnesses, surgical procedures, and current prescription medications.

7. You agree to your GP being informed of this purchase (if prescribed), and grant permission to our prescribers gaining access to your medical history, only when absolutely necessary.

8. You acknowledge and accept our Terms of Use, Terms of Sale, and Cancellation and Refund Policy and you confirm that you have reviewed and understood our Privacy Policy.

Yes

By clicking start now you agree to our Privacy Policy and confirm that you are over 18 years of age.

2 About You and Your Health

These questions help us understand who you are and your current health.

With which ethnic group do you primarily identify?

Why do we ask this? Optimal Body Mass Index (BMI) ranges may vary based on an individual's ethnic background.

3 Are you currently pregnant, trying to conceive, or breastfeeding?

Choose Option

Yes No

4 Please calculate your BMI

Please provide your height and weight so we can calculate your BMI.

Enter Details

Your BMI must be over 30 to qualify, or between 27-30 with at least one weight related comorbidity such as
pre-diabetes, diabetes, hypertension, dyslipidamia or obstructive sleep apnoea.

Please select either Metric or Imperial measurements :

Metric (Centimeters and Kilograms)

Imperial (Feet and Pounds)

Height

Feet

Inches

Weight

Stone

Pound

BMI Calculation:

5 Have you been diagnosed with diabetes?

Medications used to treat diabetes may affect how well the weight management medication in our program works in your body.

Choose Option

I have diabetes and it is diet controlled

I have diabetes and take medication for it

I do not have diabetes

I have pre-diabetes

7 Are you taking any prescribed, over-the-counter, or recreational drugs?

Choose Option

Yes No

8 Are you allergic to any medicines or other substances?

Choose Option

Yes No

9 Do you have a history of eating disorders or mental health conditions related to food or weight?

Choose a Option

Yes No

10 Have you ever used any weight loss medication?

Choose a Option

Yes No

11 Would you like to remain on your current dose or increase?

If you are not using weight loss injections, please select "I'm not using weight loss medication"

Choose an Option

Remain on my current dose

Increase dose

I'm not using weight loss medication

12 We require evidence of your current dosage.

If you are requesting a higher strength as your starting dose, please provide proof of your current dosage by uploading an image of the label on the box or a copy of your most recent prescription. Without evidence of your previous dose, our prescriber may be unable to issue a higher dose as requested.

If you have not used any medicine before, press continue and move onto the next.

Upload Here

Only images or pdf accepted

File #1

13 Have you ever experienced any side effects when using weight loss medication?

If this is the first time using weight loss medicines, select "No"

Choose an Option

Yes No

14 What is your target weight?

What is your target weight?

Weight

lbs kg

Stone

Pounds

15 How often do you exercise for a minimum of 20 minutes or more?

Choose an Option

1 - 2 times per week

3 - 5 times per week

6+ times per week

I do not exercise

16 Do you consume alcohol?

If so, please indicate the no. of units per week. Use the following guide:
- Pint of lower-strength lager/beer/cider (ABV 3.6%) = 2 units
- Standard glass of red/white/rosé wine (175ml, ABV 12%) = 2.1 units
- Can of lager/beer/cider (440ml, ABV 5.5%) = 2.4 units
- Large (35ml) single measures of spirits are 1.4 units

Choose an Option

1 - 2 times per week

2 - 4 units per week

6 - 8 units per week

I do not consume alcohol

17 Do you smoke?

Choose an Option

Yes

1 Let's Get Going!

Do you agree with the following?

2 About You and Your Health

With which ethnic group do you primarily identify?

3 Are you currently pregnant, trying to conceive, or breastfeeding?

Choose Option

4 Please calculate your BMI

Enter Details

Height

Weight

Height

Weight

5 Have you been diagnosed with diabetes?

Choose Option

6 Do any of the following apply to you?

Choose Option(s)

7 Are you taking any prescribed, over-the-counter, or recreational drugs?

Choose Option

Please describe below?

8 Are you allergic to any medicines or other substances?

Choose Option

Please describe below

9 Do you have a history of eating disorders or mental health conditions related to food or weight?

Choose a Option

Please describe below

10 Have you ever used any weight loss medication?

Choose a Option

Please describe below

11 Would you like to remain on your current dose or increase?

Choose an Option

12 We require evidence of your current dosage.

Upload Here

13 Have you ever experienced any side effects when using weight loss medication?

Choose an Option

Please explain below

14 What is your target weight?

What is your target weight?

15 How often do you exercise for a minimum of 20 minutes or more?

Choose an Option

16 Do you consume alcohol?

Choose an Option

17 Do you smoke?

Choose an Option