Screening

Screening

Full Name

ID Number

Age

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Weight (kg)

Height (metres)

BMI Result

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Do you have any of the following conditions? Tick yes/no

Hypertension

Yes

High cholesterol

Yes

Type 2 diabetes

Yes

Type 1 diabetes

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Hypersensitivity (allergy) to semaglutide or other GLP-1 agonists

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Personal or family history of medullary thyroid carcinoma (MTC)

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Multiple endocrine neoplasia syndrome type 2 (MEN2)

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Pregnant, breastfeeding, or planning to become pregnant

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Current or prior history of bulimia or anorexia

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Current or prior history of suicide attempts or suicidal ideation

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

You may still book an appointment with one of our doctors to discuss this. It is however unlikely that you will be a candidate for these medications.

Click "submit" to proceed with booking an appointment.

Kidney dysfunction

Yes

Already using a GLP-1 agonist (eg semaglutide, tirzepatide, liraglutide)

Yes

Using insulin, gliclazide, glimepiride

Yes

Do you have any medical conditions not listed above? If yes, please list.

Have you had, or are you scheduled to have, any surgeries? If yes, please list.

Are you on any medications? If yes, please list.

Do you have any allergies/hypersensitivity to any medications?

Yes

Our screening questionnaire indicates that GLP-1 agonist medications are likely safe and appropriate for you. Please book an appointment with one of our doctors.

Click "submit" to proceed with booking an appointment.

Please list allergies

Our screening questionnaire indicates that GLP-1 agonist medications are likely safe and appropriate for you. Please book an appointment with one of our doctors.

Click "submit" to proceed with booking an appointment.

Medical Screening

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