Weight loss medication assessment - Streamline Weight Loss Surgery

Step 1 of 12

Dr Eveleigh Nicholson

Medical Director of Streamline

Well done! You have taken the first step in your weight loss journey.

In this assessment, we’ll ask you a few brief medical questions to help determine if weight loss medication is the right option for you. It will only take a couple of minutes of your time.

Please note, we are only currently able to deliver to mainland United Kingdom (England, Wales & Scotland).

Your information and consent

As part of our confidentiality and GDPR policy we need your consent before proceeding. If you would like further information regarding our privacy policy, please click here.

To support you with any potential prescribed treatment we need you to share all relevant medical history and current health conditions.

By completing this form, you acknowledge Streamline's terms of service. To review our terms of sale, please click here.

I agree to the collection, storage of my information, and accept Streamline’s terms of sale.(Required)

Yes

As you declined to consent, unfortunately, we cannot assist your enquiry.

Prescribed weight loss medication

According to prescribing guidelines, weight loss medication is only suitable for adults aged between 18 to 74 years.

Are you between 18 and 74 years of age?(Required)

Yes, I confirm I meet the above age requirements

No, I don’t meet the above

Based on the information provided you may not be suitable for weight loss medication. Please call our enquiry team on 0333 016 2929 to discuss alternative weight loss options. Please note we can’t treat anyone under the age of 18.

Your key details

Title(Required)

First name(Required)

Middle name

Surname(Required)

Your contact details

Address(Required)

Please note, we are only currently able to deliver to mainland United Kingdom (England, Wales & Scotland).

Address line 1 Address line 2 Town / City County Postcode

Mobile Number(Required)

Email address(Required)

Your ethnicity

Weight loss medication should only be prescribed if your body mass index (BMI) meets medical guidelines. This can vary depending on ethnic backgrounds.

Your ethnic background(Required)

What was your assigned gender at birth?

Gender(Required)

Female

Male

Your date of birth

Date(Required)

DD slash MM slash YYYY

Height and weight

What is your height in meters?(Required)

What is your weight in kilograms?(Required)

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Height squared

Your BMI is:

Sorry, you are not eligible to continue as your BMI is below 27.
If your BMI is under 27 but you are currently taking weight loss medication and are switching to us from another provider, please get in touch with our customer care team directly on 03330 163 030 or 07795 551493, as we may still be able to assist you.

Have you been diagnosed with any of the following medical conditions?

Please tick to indicate(Required)

Asthma or COPD

Cardiovascular / heart related disease

High blood pressure

High cholesterol

Diabetes (including pre-diabetes)

Liver related disease

Kidney related disease

Thyroid related condition

Gastrointestinal related condition

Obstructive Sleep apnoea (OSA)

Polycystic ovary syndrome (PCOS)

Joint, muscle and bone conditions

Cancer related disease

I have none of the above medical conditions

Your medical history

Please tick(Required)

Do you currently take medication or have recently finished a course of medication?

Have you ever been diagnosed with any eating disorder such as anorexia, bulimia or binge eating?

Do you have or a family history of thyroid cancer including medullary (MTC) or multiple endocrine neoplasia (MEN2) disorder that affects thyroid glands?

Are you pregnant?

Are you breastfeeding?

Do you have allergies to medication?

Have you had a previous weight loss procedure?

Diagnosed mental health condition

Do you have a history of gallstones?

Do you have a history of pancreatitis?

I have none of the above

Please provide as much information as possible(Required)

Are you currently taking or have you previously taken weight loss medication?

Please select(Required)

Yes

Please provide as much information as possible(Required)

Details about your general lifestyle.

Do you currently smoke (including vaping)?(Required)

Yes

Do you drink more than 14 units of alcohol per week?(Required)

Yes

On average, do you sleep less than 7 hours per night?(Required)

Yes

On average do you exercise more than 2.5 hours per week?(Required)

Yes

Please select the following statements which apply to you.

Please tick(Required)

I mostly eat larger than average portions at mealtimes.

I mostly eat three regular meals per day.

I mostly tend to skip meals.

I mostly tend to pick / graze through the day.

I eat a well-balanced diet.

I mostly tend to eat the majority of my daily food in the evening.

I drink fizzy drinks (regular or diet) more than twice a week.

I think a lot of the calories I consume come from sugary drinks (e.g. regular fizzy drinks, fruit juice, smoothies, energy drinks, sugar in hot drinks).

I lack knowledge on what constitutes a healthy, balanced diet.

I mostly eat convenience/ready-prepared food rather than cook from scratch.

I think a lot of the calories I consume come from highly processed snack foods high in fat and sugar (e.g. crisps, chocolate, ice-cream, cakes, biscuits)

I cook from scratch most of the time.

I get a takeaway or eat out more than once a week.

My job or lifestyle makes it difficult to eat a healthy, balanced diet.

None of the above

Please enter details of any diets that you have tried previously

You have almost completed this form

Please use this section to provide any further information you think might be important to share with our medical team.

Further information (optional)

Your GP practice details

The General Medical Council expects our medical professionals to keep your GP informed about your care and treatment you may receive from us. It’s your choice if you prefer for us not to share this information with your GP.

Sharing preference(Required)

Yes, please share of information with my GP

No, do not share information with my GP

Please provide your GP email address(Required)

Understanding weight loss medication

I understand any prescribed weight loss medication should be taken as part of a weight loss programme including healthy eating and regular exercise.

I understand it’s important to read all information supplied to be regarding prescribed weight loss medication.

I understand that I experience any new or changing side effects when taking weight loss medication I need to contact Streamline and inform my GP

I understand weight loss medication may increase gall bladder related issues and pancreatitis. In addition, if I experience any upper abdominal pain I will stop taking weight loss medication immediately and contact both Streamline and my GP.

I understand weight loss medication has been linked to a lowering of mood. If I experience any depression, lowering of mood or have mental health concerns, I understand that I should stop taking weight loss medication and speak with my GP’

I understand any weight loss medication prescribed to me is for my sole use and shouldn’t be shared with others.

I am aware weight loss medication may impact the effectiveness of oral contraception and additional methods of non-oral contraception should ALSO be used.

I understand weight loss medication is not recommend with a personal history or family history of thyroid cancer

I understand that I am required to inform Streamline of any significant changes in my health, which I did not disclose at my initial assessment

I confirm that the information I provided to Streamline is accurate and truthful. I understand Streamline will prescribe my medications based on the information provided and accept that incorrect information can be harmful to my health.(Required)

Yes, I agree

No, I don't agree

You must agree before continuing

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