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Obesity

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Obesity

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Patient Information

Full Name *

Age *

Gender *

Weight (kg)

If you have any other complaints, please describe them

Height (cm)

BMI

Weight History

Lifetime Maximum Weight and When It Occurred

Period When Weight Gain Began, or Triggering Factors

Childhood / Adolescence

After Pregnancy

Menopause

Intense Stress / Change of Job

Related to Medication Use (e.g. corticosteroids)

After Smoking Cessation

Other

Methods You Have Tried So Far, and Their Results

Medical Diet and Nutrition Programmes (with a dietitian)

Intensive Exercise Programmes

Behavioural Change and Lifestyle Programmes

Drug Treatments (GLP-1 analogues, liraglutide, semaglutide, tirzepatide, etc.)

History of Obesity Surgery (sleeve gastrectomy, gastric bypass, etc.)

Herbal Products / Slimming Teas / Alternative Methods

Have you previously used a GLP-1 receptor agonist or a new-generation obesity drug?

Yes

Which drug and dose

Is there a history of regaining lost weight (yo-yo effect)?

Yes, I quickly regained more than I had lost

No / I was able to maintain it in part

Comorbidities

Do you have any additional health problems accompanying obesity?

Insulin Resistance / Prediabetes

Type 2 Diabetes

Hypertension (High Blood Pressure)

Raised Blood Lipids (Triglycerides / Cholesterol — Dyslipidemia)

Fatty Liver (MAFLD / MASH)

Obstructive Sleep Apnoea Syndrome (breathing pauses during sleep)

Joint Wear (knee/hip osteoarthritis)

Polycystic Ovary Syndrome (PCOS)

Other

Eating Behaviour and Appetite

What is your eating behaviour and appetite pattern like?

Night-eating syndrome / night-time snacking

Emotional eating (eating in response to stress, sadness or distress)

Eating quickly, with delayed satiety

Sweet cravings / carbohydrate dependence

Difficulty controlling portion size

Your Questions for the Council

Question 1

Question 2

Question 3

Tests and Reports

No tests

Hemogram (Complete Blood Count)

Biochemistry

Gastroscopy

Colonoscopy

Metabolic Evaluation Report

Imaging Reports

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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