Consultation - RX Direct

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About Your Health

About Your Condition

The Agreement and Consent

Weight loss refers to the reduction of body weight, typically through a combination of diet, exercise, and lifestyle modifications. It is often pursued for health reasons, such as reducing the risk of chronic diseases like diabetes, heart disease, and certain cancers, as well as improving overall well-being and quality of life. Effective weight loss strategies focus on creating a calorie deficit, where the number of calories consumed is less than the calories expended. This can be achieved through diet changes and regular exercise. Sustainable weight loss involves making gradual and lasting changes to eating and exercise habits, as well as addressing emotional and behavioural factors that contribute to overeating or sedentary lifestyles.

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Please provide your full name

Please provide your email address

Please provide your mobile number

What is your date of birth?

What is your gender?

Female

Male

Do you have any known allergies?

Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Do you smoke?

Do you consume alcohol?

If yes, how much a day/weekly?

How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Please calculate your current BMI.

Please select either Metric or Imperial measurements :

Metric (Centimeters and Kilograms)

Imperial (Feet and Pounds)

Height

Feet

Inches

Weight

Stone

Pound

BMI Calculation:

What are your weight loss goals? (e.g., lose a certain number of pounds/kilograms, achieve a specific BMI)

Have you tried to lose weight before?

What has been your experience with previous weight loss attempts? (e.g., successful, temporary weight loss, no weight loss)

Are you currently experiencing any symptoms that may be related to your weight? (e.g., joint pain, shortness of breath, fatigue)

Have you been diagnosed with any conditions that could affect your weight or ability to lose weight? (e.g., metabolic syndrome, hypothyroidism)

Have you had any tests to evaluate your condition? (e.g., blood tests, metabolic tests)

Have you been prescribed medication for weight loss before?

Are you currently taking any medication for weight loss?

Have you experienced any side effects from your current or past weight loss medications?

Have you tried any non-medication treatments for weight loss? (e.g., lifestyle changes, dietary adjustments, physical therapy)

Have you used over-the-counter treatments for weight loss?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for Weight Loss.

Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

Video Consultation

Due to new regulations, we are required to have a 5-minute video call to verify your weight before we can supply weight loss treatment.

Once you place your order, we will email you to book a call with our specialist via FaceTime, WhatsApp Video, Google Meet, Microsoft Teams, or Zoom.

Please confirm that you understand and are happy to proceed with this requirement.

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

Acid Reflux

Contraceptives

Erectile Dysfunction

Hair Loss

Period Delay

Premature Ejaculation

Weight Loss

Weight Loss

1 About Your Health

Please provide your full name

Please provide your email address

Please provide your mobile number

What is your date of birth?

What is your gender?

Do you have any known allergies?

Yes

Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Are you currently taking any medications?

Yes

Have you had any surgeries in the past year?

Yes

Do you smoke?

Yes

Do you consume alcohol?

Yes

How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please calculate your current BMI.

Height

Weight

Height

Weight

What are your weight loss goals? (e.g., lose a certain number of pounds/kilograms, achieve a specific BMI)

Have you tried to lose weight before?

Yes

What has been your experience with previous weight loss attempts? (e.g., successful, temporary weight loss, no weight loss)

Are you currently experiencing any symptoms that may be related to your weight? (e.g., joint pain, shortness of breath, fatigue)

Yes

Have you been diagnosed with any conditions that could affect your weight or ability to lose weight? (e.g., metabolic syndrome, hypothyroidism)

Yes

Have you had any tests to evaluate your condition? (e.g., blood tests, metabolic tests)

Yes

Have you been prescribed medication for weight loss before?

Yes

Are you currently taking any medication for weight loss?

Yes

Have you experienced any side effects from your current or past weight loss medications?

Yes

Have you tried any non-medication treatments for weight loss? (e.g., lifestyle changes, dietary adjustments, physical therapy)

Yes

Have you used over-the-counter treatments for weight loss?

Yes

3 The Agreement and Consent

Understanding of Risks

Medical Guidance

Consent to Share Information

Confirmation

Video Consultation

Assessment Progress