Weight Loss - Puri Pharmacy

Step 1 of 69

Some important questions

You are completing this consultation for yourself and to the best of your knowledge.
You will disclose any medical conditions, serious illnesses or operations you have had.
You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time.
You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy.
Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.

Hello 👋,
In the following steps, we'll ask about your age, medical history, and current health to ensure that weight loss treatment is safe and suitable for you.

Takes <5 minutes on average
Reviewed by a UK clinician

How old are you?*

Under 18

18 to 74

75 or over

❌
No suitable treatment

Based on the responses provided in this consultation, we cannot recommend any of our treatments at this time.

Which ethnicity are you?*

Healthy BMI ranges are different according to your ethnic background.

Asian or Asian British

Black (Caribbean, African)

Mixed ethnicities

Other ethnic group

White

What sex were you assigned at birth?*

Male

Female

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

Yes

❌
No suitable treatment

Based on the responses provided in this consultation, we cannot recommend any of our treatments at this time.

What is your weight?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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What is your height?

Height (cm)*

Height (ft)*

Height (in)*

Height metrics*

ft/in

This field is hidden when viewing the form

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Have you been diagnosed with diabetes?*

Diabetes treatments can impact the way the medication included with our weight loss plan works.

I have diabetes and take medication for it

I have diabetes and it's diet-controlled

No, but there is history of diabetes in my family

I have pre-diabetes

I don't have diabetes

Do any of the following statements apply to you?*

These conditions can lead to serious complications when losing weight or taking weight loss medications.

I have chronic malabsorption syndrome (problems absorbing food)

I have cholestasis

I'm currently being treated for cancer

I have diabetic retinopathy

I have severe heart failure

I have a family history of thyroid cancer and/or I've had thyroid cancer

I have end-stage kidney disease

I have a history of pancreatitis

I have or have had an eating disorder such as bulimia, anorexia nervosa, or a binge eating disorder

I have had surgery or an operation to my thyroid

I have had a bariatric operation such as gastric band or sleeve surgery

None of these statements apply to me

❌
No suitable treatment

Based on the responses provided in this consultation, we cannot recommend any of our treatments at this time.

Do any of the following statements apply to you?*

These conditions are often weight related and may be improved as a result of losing weight.

I have been diagnosed with a mental health condition such as depression or anxiety

My weight makes me anxious in social situations

I have joint pains and/or aches

I have osteoarthritis

I have GORD and/or indigestion

I have a heart/cardiovascular problem

I've been diagnosed with, or have a family history of, high blood pressure

I've been diagnosed with, or have a family history of, high cholesterol

I have fatty liver disease

I have sleep apnoea

I have asthma or COPD

I have erectile dysfunction

I have low testosterone

I have menopausal symptoms

I have polycystic ovary syndrome (PCOS)

None of these statements apply to me

Please tell us more about your mental health condition and how you manage it*

Do you have any other medical conditions?*

Our clinicians need to know your full medical history to make sure our weight loss plan is safe for you.

Yes

Please list any other medical conditions you have.*

Our clinicians need to know your full medical history to make sure our weight loss plan is safe for you.

Have you ever taken any of the following medications to help you lose weight?*

Wegovy

Ozempic

Saxenda

Rybelsus

Mounjaro

Alli

Mysimba

Other

I have never taken medication to lose weight

What was your weight in kg before starting Wegovy?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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When was your last dose of Wegovy?*

Less than 4 weeks ago

4-6 weeks ago

More than 6 weeks ago

What dose of Wegovy were you prescribed most recently?*

0.25mg

0.5mg

1mg

1.7mg

2.4mg

Other

What dose of Wegovy were you prescribed most recently?*

If you want to continue with Wegovy, what dose would you like to continue with?*

A clinician will review your answers and select your dosage as appropriate. Price varies by dosage.

Increase my dose

Keep my dose

Decrease my dose

I don't want to continue with this medication

Have you experienced any side effects with Wegovy?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

What was your weight in kg before starting Ozempic?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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When was your last dose of Ozempic?*

Less than 4 weeks ago

4-6 weeks ago

More than 6 weeks ago

What dose of Ozempic were you prescribed most recently?*

0.25mg

0.5mg

1mg

Other

What dose of Ozempic were you prescribed most recently?*

Have you experienced any side effects with Ozempic?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

What was your weight in kg before starting Saxenda?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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Please provide the date of your last Saxenda dosage in dd/mm/yyyy.*

What dose of Saxenda were you prescribed most recently?*

0.6mg

1.2mg

1.8mg

2.4mg

3mg

Other

What dose of Saxenda were you prescribed most recently?*

Have you experienced any side effects with Saxenda?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

What was your weight in kg before starting Rybelsus?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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When was your last dose of Rybelsus?*

Less than 4 weeks ago

4-6 weeks ago

More than 6 weeks ago

What dose of Rybelsus were you prescribed most recently?*

3mg

7mg

14mg

Other

What dose of Rybelsus were you prescribed most recently?*

Have you experienced any side effects with Rybelsus?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

What was your weight in kg before starting Mounjaro?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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When was your last dose of Mounjaro?*

Less than 4 weeks ago

4-6 weeks ago

More than 6 weeks ago

What dose of Mounjaro were you prescribed most recently?

2.5mg

5mg

7.5mg

10mg

12.5mg

15mg

Other

What dose of Mounjaro were you prescribed most recently?*

If you want to continue with Mounjaro, what dose would you like to continue with?*

A clinician will review your answers and select your dosage as appropriate. Price varies by dosage.

Increase my dose

Keep my dose

Decrease my dose

I don't want to continue with this medication

Have you experienced any side effects with Mounjaro?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

What was your weight in kg before starting Alli?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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Are you currently taking Alli?*

Yes

Have you experienced any side effects with Alli?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

What was your weight in kg before starting Mysimba?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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Are you currently taking Mysimba?*

Yes

Have you experienced any side effects with Mysimba?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

Which weight loss medication(s) have you tried?*

You only need to tell us about medications you have not yet told us about.

What was your weight in kg before you started taking this medication?

Weight (kg)*

Weight (St)*

Weight (Lbs)*

Weight metrics*

st/lbs

This field is hidden when viewing the form

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Are you taking this medication currently?*

Yes

Have you experienced any side effects?*

Yes

Please tell us as much as you can about your side effects - the type, duration, severity and whether they have resolved.*

Do you currently take any other medication or have any allergies? This includes prescribed medication, over-the-counter medication, and supplements. Select all that apply to you.

It’s really important that we know about any medication you're taking so that we can make sure there are no interactions with your weight loss plan.

I'm on levothyroxine

I'm on warfarin

Other / I take more than one prescription medication

I don't take any medication

I have allergies

Please include a full list of all medication that you currently take.

Please list any allergies you have.

It’s important that our clinicians are aware of any allergies you have to make sure the medication prescribed won’t be harmful.

Would you like your GP to be informed of this consultation?*

To ensure we provide the best and safest service for you, we strongly encourage you to share your GP details so we can inform them about your treatment. If you are aware of your GP practice's email address, please enter them on the next screen.

Yes

Please enter your GP's email address*

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