Eligibility Quiz

Page 1

I am over 18 years old and live in the UK*

I am over 18 I live in the UK I can verify my identity

I will be the sole user of any medication offered to me through this service*

I will be the sole user I will not share the medication I will store it safely

I confirm all answers are provided by me and are completely truthful*

The answers are my own They are completely truthful I will report any changes

Page 2

Are you currently taking any kind of weight loss medication?

Yes No I recently stopped

What is the name of the weight loss medication you are taking?

What dosage are you taking on your current prescription?

Do you wish to continue taking this medication?

Yes No I haven't decided

Can you let us know why you do not wish to continue with your current medication?

What is your reason for transferring your care? Please select all that apply.

Reason:

What weight changes have you had since you started weight loss medication/injections?

What was your BMI when you began taking weight loss medication?

Tell me about yourself and your weight loss goals

Page 3

Which medication are you interested in buying?

Wegovy Mounjaro Saxenda Rybelsus Not sure yet

Gender*

Female Male Non-binary Prefer not to say

What is your Ethnicity?

White Black, African or Caribbean South Asian East Asian Mixed or multiple Other Prefer not to say

BMI

Page 4

Are you Pregnant, breastfeeding or trying to conceive?*

Yes, I am pregnant Yes, I am breastfeeding I am trying to conceive No, none of these

Blood Pressure: You must have had your blood pressure checked in the last 6 months and be aware of the results.*

Are you undergoing any investigations with your GP or on the waiting list to have elective surgery?*

If you have answered yes to the previous answer, could you please give brief details in the text box below.

Do you, or have you ever, suffered from any of the from any of the following?

Type 2 diabetes Thyroid disorder Pancreatitis Gallbladder disease Kidney disease Liver disease

Do you, or have you ever, suffered from any of the from any of the following?

Heart disease High blood pressure Stroke Cancer Medullary thyroid cancer or MEN2 None of these

Are you taking any of the medications below? (leave blank if no)

Insulin Sulfonylureas Warfarin or blood thinners Steroids Antidepressants

Please add details (for how long and for what reasons)

Are you taking any other medications?*

Yes No Not sure

Please list other medications

Have you ever had bariatric surgery?*

Yes No I have one scheduled

What surgery did you have?

When did you have bariatric surgery?

Do you have any allergies to Saxenda, Rybelsus, Wegovy, Ozempic,Trulicity or Victoza?*

Yes No Not sure

Page 5

What are your main reasons for wanting to lose weight? Select all that apply

Improve my overall health Move more easily Feel more confident Doctor's recommendation An important event Improve my fertility

Specific health condition you are wanting to avoid or manage:

How much exercise do you currently do a week?

None 1 to 2 sessions 3 to 4 sessions 5 or more sessions

How long have you struggled with your weight?

Less than 1 year 1 to 5 years 5 to 10 years More than 10 years My whole life

Have you ever suffered from any of the following?

Depression Anxiety Eating disorder Self-harm None

What have you tried in the past to lose weight? Select all that apply

Calorie-controlled diets Gym or exercise Slimming clubs Medication Intermittent fasting Personal trainer

Other:

When considering treatment options, which of the following are important to you?

Effectiveness Price Fewer side effects Ease of use Ongoing support

Page 6

Name*

First Name

Last Name

DOB*

Address*

Street Address

City

State / Province

ZIP / Postal Code

Email*

Please upload a full length photo of yourself which was taken in the last 4 weeks.

Max 10 MB per file

Please upload a photo or scan of your photo ID (eg. driving licence or passport)

Max 10 MB per file

Your NHS Doctor's Info: Would you like us to contact your doctor informing them of what medicine we have provided after your treatment plan is shipped? This is optional for most conditions, however for some chronic conditions we cannot treat you unless we have permission to inform your NHS GP*

Yes, inform my doctor No, do not inform them I'd like to discuss it first

Email address for your GP surgery

Name of my usual GP:

Patient declarations

You are required to read the Patient Information Leaflet supplied with your medication*