Consultation - Pharmaceutra

What is your current height?

Height

ft/in

cm

Feet

Inches

What is your current weight?

Weight

lbs

kg

Stone

Pounds

Do you have a goal weight you would like to achieve?

What is your age?

18-74

75-84

What is your biological sex?

Male

Female

Are you currently pregnant, trying to get pregnant, or breastfeeding?

Yes

No

What is your ethnicity?

Have you been diagnosed with any of these medical conditions?

Do you have any of the following conditions?

Severe Liver or kidney problems
Heart failure
History of Pancreatitis (Inflammation of the pancreas)
Multiple endocrine neoplasia type 2 (a rare hormone-related disorder)
A cancer that requires monitoring or treatment
Type 1 diabetes
Diabetes-related eye problems (such as diabetic retinopathy)
Personal or family history of thyroid cancer
A current eating disorder or a history of an eating disorder? (e.g., anorexia, bulimia, binge eating disorder)
A history of gallstones (if you still have your gallbladder)
Severe digestive conditions, including Ulcerative Colitis, Crohn’s Disease, or gastroparesis (delayed stomach emptying)
Glaucoma, epilepsy, or porphyria

Do you have gallbladder, gallstones or bile duct issues?

yes

No

Could you please provide more information about your gallbladder issues?

I am currently experiencing or have previously experienced gallastones

I have had my gallbladder removed

Other

When did you have surgery to remove your gallbladder?

More than 3 months ago

Less than 3 months ago

Do you have a history of any kidney or liver conditions?

Have you ever had bariatric weight-loss surgery or a gastric band procedure?

Yes

No

Which of the following surgeries or procedures did you have?

Balloon

Gastric Bond

Gastric Bypass

Did you have this surgery or procedure in the last 12 months?

Yes

No

Have you been diagnosed with any other health condition(s)?

Do you have any allergies?

Are you taking any of the following medication?

Epilepsy medications
Such as Carbamazepine, Phenytoin, Primidone, Sodium Valproate/Valproic acid, Zonisamide, Phenobarbital, Divalproex, Ethosuximide
Medications for your heart rate
Such as Flecainide, Quinidine, Procainamide, Disopyramide
Digoxin or Digitoxin
Immunosuppressants
Such as Cyclosporine, Tacrolimus, Everolimus or Sirolimus
Medications that require close monitoring
Such as Lithium, Methotrexate tablets for cancer therapy, Theophylline, Colchicine or Isoprenaline
Warfarin or Acenocoumarol
Insulin
Sulfonylureas e.g. gliclazide
Orlistat

Do you currently take any other medication?

Which option would you prefer if both were clinically appropriate?

Weekly Injection

Daily Tablets

Do you confirm the following?

The information I have provided is true and accurate to the best of my knowledge.
The information I have provided will be used by the prescribers to decide whether it is appropriate to supply medication.
I understand that failure to give accurate information may result in a refusal to supply medication, or the supply of medication that is not suitable.

Yes

No

Please check you understand and agree to this treatment information:

I understand that injectable weight-loss treatments are associated with an increased risk of acute pancreatitis (including severe, necrotising or rare fatal cases). If I experience severe, persistent abdominal pain that may radiate to my back and may be accompanied by nausea and vomiting, or any worsening symptoms, I will stop the treatment and seek urgent medical help.
I understand that severe diarrhoea for over 24 hours, or vomiting within 3 hours of taking the contraceptive pill, can reduce its effectiveness. If this happens, I will call my GP or 111 for advice. I understand I may need a repeat dose of the contraceptive pill or to use additional contraception.
I understand that Wegovy is associated with a very rare risk of non-arteritic anterior ischemic optic neuropathy (NAION); a condition that can cause sudden changes in vision or vision loss. If I experience sudden changes in eyesight, blurring, cloudiness, or loss of vision, I will stop the treatment and seek urgent medical assessment.
I understand that rapid weight loss and injectable weight loss treatments like Mounjaro, Wegovy and Nevolat should not be combined with other weight loss medications.
I recognise that these treatments may affect my mood. If I experience low mood or any mental health issues, I will stop the treatment and consult a doctor immediately.

Yes

No

I agree and understand the below:

The treatment is solely for my own use and I understand that I cannot supply medication prescribed for me to anyone else.
I will read the patient information leaflet supplied with the medication.
I will contact Cloud Pharmacy and inform my GP if I experience any side effects from treatment, begin any new medication, or if my medical conditions change during the course of treatment.
I agree to Cloud Pharmacy notifying my GP that I am taking GLP-1 weight loss medication and to allow my GP to share information with Cloud Pharmacy if they have any concerns.
I am aware that I will be subject to a soft check to validate my identity via LexisNexis.
I give my permission for Cloud Pharmacy to request further medical information from my GP if necessary.
I agree to Cloud Pharmacy terms and conditions and privacy policy.
I accept the terms and conditions of this service

Yes

No

Acid Reflux

Acne

Contraception

Eczema

Erectile Dysfunction

Hair Loss

HRT

Malaria Prevention

Premature Ejaculation

UTI

Weight Loss

Assessment for Weight Loss

Weight Loss

1 About Your Health

What are your main reasons for wanting to lose weight?

Are you currently using any weight loss treatments?

Which medication are you using?

Have you previously used any weight loss treatments?

What was your weight when you started treatment?

Do you have proof of previous medication supplies?

What phase of your weight management journey are you in?”

Is there any other information you would like to add to help our prescriber make their decision in how best to support your individual needs?

Please provide information below

2 Your BMI