Simple Online Pharmacy | Weight care Assessment

1. About You

In progress

Question 1What was your sex registered at birth? (i.e your biological sex) *

MaleFemale

Question 2What is your height? *

feet

inches

Question 3What is your current weight? (It's really important you give us an accurate up-to-date measurement. You may be asked to provide evidence of your current weight) *

stone

pounds

Question 5Do you have any of the following conditions? *

Severe heart failureKidney impairmentDiabetic retinopathyPancreatitis (current or previous issues)GastroparesisUlcerative colitis or Crohn's diseaseHistory or family history of Thyroid cancer, medullary thyroid cancer or MEN2Any cancer, current chemotherapy or radiotherapyNone of the above

Question 6Do you have gallbladder or bile duct issues? *

YesNo

Question 7Do you have liver impairment? *

YesNo

Question 8Do you have diabetes? *

I have pre-diabetes/diet controlled diabetesYes and I take medication for my diabetesNo

Question 10Have you ever made yourself sick (vomit) to control your shape or to lose weight? *

YesNo

Question 11In the last 12 months, have you done any of the following to influence your weight or shape: used laxatives or diuretics, or engaged in behaviours such as excessive exercise or unhealthy fasting? *

YesNo

Question 12In the last 3 months, have you had episodes where you felt out of control when eating (for example, eating more than you intended and feeling unable to stop)? *

YesNo

Question 13Do thoughts about food, eating, weight, calories, or your body shape take up a lot of your time or cause you significant distress? *

YesNo

Question 14In the last 3 months, have you regularly eaten in secret because you felt embarrassed, ashamed, or out of control? *

YesNo

2. Your Medical History

Incomplete

3. Your Treatment

Incomplete

4. Acknowledgements

Incomplete

To ensure you understand key information about your treatment, read the below statements carefully and acknowledge understanding.

I understand I should use one weight loss product at any one time
I understand that the best and safest weight loss outcomes are achieved by slowly and carefully titrating the dose as per the dose escalation schedule to gain the maximum benefit from the medication. I understand that if I have a gap in treatment longer than 2 weeks, I may need to reduce my dose to avoid side effects.
I understand that Wegovy/Mounjaro is used as an injection under the skin (subcutaneous injection). I will not inject it into a vein or muscle. The best places to give the injection are the upper arms, stomach or upper legs. I will ensure to drink plenty of fluids to avoid dehydration. I can find detailed instructions on using Wegovy/Mounjaro in the Patient Information Leaflet in the box.
By ordering, you are giving consent for the prescriber to check your Summary Care Record should they feel it necessary to make a clinical decision.
I understand that I will stop treatment and inform Simple and/or seek medical attention if I experience severe dehydration, e.g. dark urine, confusion, blood in stool or vomit, diarrhoea lasting longer than 72 hours, or being unable to keep food down without vomiting/diarrhoea.
I understand that It is important for female patients to use reliable contraception throughout treatment with Wegovy and Mounjaro. You must stop Wegovy at least 8 weeks before trying to conceive and Mounjaro at least 4 weeks before trying to conceive. If you use oral hormonal contraception (such as the pill) while on Mounjaro, you will need to use additional barrier methods of contraception (such as condoms) for 4 weeks when starting treatment and each time you increase to a new dose. If you become pregnant while using either treatment, discontinue use immediately and consult your GP. Please tick to confirm you have read and understood this information.
I understand that if I experience any troublesome side effects from Wegovy/Mounjaro, I can contact Simple Online Pharmacy, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the Patient Information Leaflet.

Please tick the box to confirm that you understand and agree with the statements above.

I confirm that I understand that if I place an order for Wegovy/Mounjaro after 12pm on a Saturday, Simple Online Pharmacy will not ship my order until Monday (unless a public holiday) due to the medication being a temperature/time critical item. This applies even if you choose the 'next day delivery' option on the checkout page.
I confirm this treatment is for me, and I consent to this treatment. If Wegovy/Mounjaro does not help me realise my weight loss aims, I will consult my GP for further advice. I take responsibility to inform Simple Online Pharmacy and/or my own regular doctor of any changes in my circumstances. I agree to the Simple Online Pharmacy terms and conditions.
I confirm that all the above information is truthful and accurate. I agree to inform SOP of any change to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed.

Please tick the box to confirm that you understand and agree with the statements above.