New Form Submission

Dear Team,

You have received a new submission from the Weight Loss Form. Below are the details provided by the respondent.

Full Name:	{patientsName}
Date of Birth:	{dateOf}
Email Address:	{email}
Phone Number:	{phoneNumber}
Assigned Sex at Birth:	{assignedSex}
Are you between the ages of 18 and 74?	{areYou23}
Current Weight (kg):	{whatIs}
Current Height (cm):	{whatIs20}
Do you suffer from prediabetes, heart disease, high blood pressure, high cholesterol or obstructive sleep apnoea?	{doYou33}
Do you suffer from diabetes?	{doYou24}
If you have type 2 diabetes, are you on any injections or tablets to control your blood sugar, other than metformin?	{ifYou}
Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before?	{haveYou}
Have you ever suffered with an eating disorder?	{haveYou27}
Are you pregnant, breastfeeding, or trying to conceive?	{areYou}
Have you been diagnosed with or had surgery for any of the following?	{haveYou29}
Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?	{doYou}
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?	{areYou35}
Are you taking steroids or medication to treat your thyroid?	{areYou36}
Have you taken injectable weight loss medication in the last 4 weeks?	{haveYou37}
Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you:	{doYou38}
Do you understand that GLP-1 injectable weight-loss medication (such as Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment?	{doYou39}
Do you understand that this medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?	{doYou40}
Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?	{doYou41}
Do you understand that injectable weight loss medications should not be used with other weight loss medications?	{doYou42}
Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?	{doYou43}
Both weight loss and injectable weight loss treatment has been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental health issues), do you understand you should stop treatment and speak to your doctor?	{bothWeight}
Appointment Scheduled:	{appointment}