Weight Management Screening Form - Watcom Health Lab & Beauty Academy

07862 653508

support@watcomivhealthandbeauty.com

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Full name *

Email address *

Mobile number *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of birth *

Age *

May Watcom notify your GP if clinically necessary? *YesNo

Please select any that currently apply or have applied to you *Select all that apply. Choose ‘None of these’ only if no listed condition applies.None of thesePregnant, trying to become pregnant or breastfeedingHeart or circulation conditionDigestive, stomach, pancreatic or gallbladder conditionKidney conditionLiver conditionThyroid condition or thyroid cancer historyDepression, severe low mood or suicidal thoughtsCurrent or previous eating disorder

Allergies, medicine reactions and current medicines *Include prescribed medicines, non-prescribed medicines, vitamins and supplements. Write ‘None’ if not applicable.

GP name and practice address *Provide your GP’s name and full practice address.

Current weight and height *Include units, for example kg and cm.

Relevant medical history, previous surgery and previous weight-management treatment *Include any relevant diagnoses, operations, hospital care or previous weight-management support. Write ‘None’ if not applicable.

Declaration and consent

This is an initial screening form. Submission does not confirm treatment suitability, prescribe treatment or create an appointment.

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Declaration and consent

This is an initial screening form. Submission does not confirm treatment suitability, prescribe treatment or create an appointment.

Schedule your visit online

Take the next step and schedule an appointment today

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