Are you aged between 18 and 74?
What is your current Weight and Height?
This helps us calculate your BMI and check if you’re eligible for treatment safely and accurately.
Metric
Imperial
Have you been diagnosed with any health conditions that are often linked to weight?
Please choose the option that best describes you:
Healthy BMI ranges are different according to your ethnic background.
Do you have any allergies to the following medications?
This helps us ensure the treatment we offer is safe for you.
If you have type 2 diabetes, do you take medications other than metformin to control your blood sugar?
e.g. insulin, gliclazide, sitagliptin, dapagliflozin
Have you been diagnosed with or had surgery for any of the following?
These conditions can make weight-loss medications unsafe, so it’s important we check before continuing.
Gallbladder issues
surgery/ removal within the last 1 year, gallstones that have not been removed, infection, bile duct/flow issues
Pancreatitis
Hypoglycaemia
low blood sugar
Liver Cirrhosis or Transplant
Severe Chronic Kidney Disease (CKD)
An Eating Disorder e.g. anorexia or bulimia
Any cognitive or memory condition
such as dementia that may affect your ability to make informed decisions.
Severe gastrointestinal disease
e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease or gastroparesis (delayed stomach emptying)
Chronic Malabsorption Syndrome
celiac disease
Weight-loss surgery or a gastric procedure in the past 12 months
Includes includes gastric band (placement or removal), sleeve gastrectomy, gastric bypass, gastric balloon, endoscopic sleeve gastroplasty, or biliopancreatic diversion.
An endocrine
(hormone-related) condition e.g. an overactive thyroid awaiting radioactive iodine or surgery, acromegaly, Addison’s disease, Cushing’s syndrome, congenital adrenal hyperplasia, or a growth hormone disorder.
Major surgery in the last 3 months
A personal or family history of Medullary Thyroid Cancer (MTC), Thyroid cancer, or Multiple Endocrine Neoplasia 2 (MEN2) syndrome
Any cancer diagnosis currently being managed by a specialist
Do you have any other medical conditions?
These conditions can make weight-loss medications unsafe, so it’s important we check before continuing.
Are you taking any of the following prescription medications?
• Amiodarone
• Carbamazepine
• Ciclosporin
• Clozapine
• Digoxin
• Fenfluramine
• Lithium
• Oral Methotrexate
• Phenobarbital
• Phenytoin
• Somatrogon
• Tacrolimus
• Theophylline
• Warfarin
Do you take any medications to treat your thyroid or any steroid medications?
What sex were you assigned at birth?
Have you ever taken any of the following medications to help you lose weight?
When did you last take ?
What was the last dose of you were taking?
When did you first start using
Please provide the approximate month and year if you’re not sure.
What was your weight approximately 1 month ago?
kg
st/lb
What was your weight when you first started
kg
st/lb
Did you experience any side effects while taking
Please describe any side effects you experienced while taking
If you’re switching to Lotus from another provider, please tell us:
Which provider were you using previously?
What is your main reason for switching to Lotus?
Do you understand that:
• First-time users must begin with the lowest dose (starter dose)
• If you've used injections successfully for at least 1 month with no issues, you may step-up to the next dose
• If you're switching to Lotus from another provider, you will need to provide evidence of previous use of weight loss medication (e.g. a screenshot of a previous order or a photo of your medication box label).