Weight Loss · Online Uk Pharmacy

Before you begin: your answers are reviewed by a UK-registered prescriber and kept confidential. Please answer honestly and in full — it's what keeps your treatment safe. Do you understand and agree to answer honestly? Yes, I understand No

What was your sex registered at birth? Female Male

How old are you? < 18 18 - 75 > 75

What is your family/ethnic background?

This is used to apply the correct BMI threshold.

White South Asian Chinese or other Asian Middle Eastern Black African or African-Caribbean Mixed or other Prefer not to say

Your height and weight

We use this to work out your BMI. Choose the units you know.

Metric (cm, kg) Imperial (ft, st)

Height cm

Weight kg

Height ft in

Weight st lb

Your BMI is worked out automatically and checked by the pharmacist.

Do you have a target weight in mind? Yes No

Do you have any of these weight-related conditions? Type 2 diabetes High blood pressure High cholesterol Obstructive sleep apnoea Pre-diabetes Polycystic ovary syndrome (PCOS) None of these

Have you ever made yourself vomit, or used laxatives, diuretics or excessive exercise, to control your weight or shape? Yes No

Are you currently having thoughts of harming yourself or that life is not worth living? Yes No

Do you have any surgery or procedure under general anaesthetic or sedation planned in the next few weeks? Yes No

Do you have, or have you ever had, any other medical conditions or operations not listed above — for example neurological (stroke/Parkinson's), breathing (asthma/COPD), or mental-health conditions? Yes No

Are you currently taking any medicines (prescription, pharmacy, or herbal/supplements)? Yes No

Are you currently taking any of the medicines listed here?

Amiodarone, carbamazepine, ciclosporin, clozapine, digoxin, fenfluramine, lithium, mycophenolate mofetil, oral methotrexate, phenobarbital, phenytoin, somatrogon, tacrolimus, theophylline, warfarin.

Yes No

Are you currently using hormonal contraception (pill, patch, implant, injection or hormonal coil)?

Weight-loss injections can slow stomach emptying, which may affect how well the oral contraceptive pill is absorbed.

Yes No

Which type of hormonal contraception do you use? Combined pill (oral) Progestogen-only / mini pill (oral) Patch Implant Injection Hormonal coil (IUS)

Are you allergic to any medicines or other substances? Yes Not sure No

Are you pregnant, breastfeeding, or trying to become pregnant? Yes No

If you can become pregnant, are you using reliable contraception? Yes No Not applicable

Do you use hormone replacement therapy (HRT)? Yes No

Which type of HRT do you use? Tablets (oral) Patch Gel or spray Mirena coil Other or not sure

Do you smoke? Yes No

How many units of alcohol do you drink per week? None 1 to 14 15 to 35 More than 35

Do you understand that this medication works alongside a reduced-calorie diet and increased physical activity? Yes No

Are you currently getting weight-loss medication from any other pharmacy, clinic or prescriber? Yes No

Is this your first weight-loss treatment course, or are you continuing existing treatment? First course Continuation

Have you used any weight-loss medication before (e.g. Mounjaro, Wegovy, Saxenda, Orlistat)? Yes No

Which weight-loss medication did you most recently use?

Tirzepatide = Mounjaro; semaglutide = Wegovy; liraglutide = Saxenda.

Mounjaro Wegovy Saxenda Other

Which dose of Mounjaro were you taking? 2.5 mg 5 mg 7.5 mg 10 mg 12.5 mg 15 mg Not sure

Which dose of Wegovy were you taking? 0.25 mg 0.5 mg 1 mg 1.7 mg 2.4 mg Not sure

Which dose of Saxenda were you taking? 0.6 mg 1.2 mg 1.8 mg 2.4 mg 3 mg Not sure

Did you have any side effects with previous treatment (for example nausea, vomiting or constipation)? Yes No

When did you last take it? Within the last 4 weeks 1 to 3 months ago More than 3 months ago

Which weight-loss medication are you currently taking?

Tirzepatide = Mounjaro; semaglutide = Wegovy; liraglutide = Saxenda.

Mounjaro Wegovy Saxenda Other

Which dose of Mounjaro are you currently on? 2.5 mg 5 mg 7.5 mg 10 mg 12.5 mg 15 mg Not sure

Which dose of Wegovy are you currently on? 0.25 mg 0.5 mg 1 mg 1.7 mg 2.4 mg Not sure

Which dose of Saxenda are you currently on? 0.6 mg 1.2 mg 1.8 mg 2.4 mg 3 mg Not sure

How long have you been taking it? Less than 1 month 1 to 3 months 3 to 6 months 6 to 12 months More than 12 months

Have you had any side effects so far (for example nausea, vomiting or constipation)? Yes No

What would you like to continue with?

The prescriber confirms suitability and the correct next dose.

Mounjaro Wegovy

Which strength of Mounjaro are you requesting? 2.5 mg 5 mg 7.5 mg 10 mg 12.5 mg 15 mg Not sure / please advise

Which strength of Wegovy are you requesting? 0.25 mg 0.5 mg 1 mg 1.7 mg 2.4 mg Not sure / please advise

Can you provide evidence of your previous supply (e.g. a pharmacy label, dispensing receipt, or previous order)?

Optional. If you can't provide it now, we'll request it before anything is dispensed.

Yes, I can provide it Not right now

This medicine works alongside a reduced-calorie, balanced diet and more physical activity — it is not a substitute for them, and keeping well hydrated is important. Do you understand? Yes No

These injections can cause side effects — commonly nausea, vomiting or constipation, and rarely inflammation of the pancreas (pancreatitis). Because of a possible thyroid-tumour risk seen in animal studies, they must not be used if you or a close relative has had medullary thyroid cancer or MEN2. Do you understand? Yes No

This medicine must not be used in pregnancy or while breastfeeding, and should be stopped well before trying to conceive. Do you understand? Yes No

This is a self-given injection under the skin (tummy, thigh or upper arm), usually once a week, and pens or needles must never be shared with anyone. Do you understand? Yes No

Your medicine is temperature-sensitive: please refrigerate it on arrival and follow the in-use storage guidance in the patient information leaflet. Do you understand? Yes No

Because it is a cold-chain medicine, it is sent on a tracked/guaranteed delivery service, and delivery timing can be affected by weekends and public holidays. Do you understand? Yes No

Is there anything else you would like to tell the prescriber? Yes No

Do you consent to us informing your NHS GP that you have started this treatment?

We think it’s safest to keep your regular GP in the loop about your care. If you don’t consent, we’re unable to continue with this treatment.

Yes, please inform my GP No, do not inform my GP

Which is your GP practice?

Start typing your surgery name or postcode and pick it from the list.

Can’t find your practice? Enter it manually

Please confirm all of the following: you will read the patient information leaflet supplied; you are 18 or over; the treatment is for your use only; you have answered every question truthfully and accurately; and you agree to our terms & conditions, privacy policy and acceptable-use policy. Yes, I confirm No

Do you agree to OnlineUKPharmacy accessing your GP Summary Care Record if the prescriber needs to? Yes No

I understand that if this treatment is not suitable I will be refunded and signposted to appropriate care, and that the final prescribing decision always rests with the prescriber. Yes, I understand No