Medical Screening form – Sure plan & Lipotrim Your Name (required) Your Email (required) Your Telephone (required) Your Address (required) Your Date of Birth (required) Your Height (required) Your Weight (required) Gender?MaleFemale Your Doctor's surgery details (required) Have you watched the Lipotrim Patient Education Video? YesNo Have you used the Lipotrim Programme before? YesNo _________________________________________________________________ Now please answer the following as fully as possible: Heart Trouble? YesNo Chest Pain? YesNo High Blood Pressure? YesNo Palpitations, faints, blackouts? YesNo Asthma, bronchitis, persistent cough? YesNo Heartburn, gastric or duodenal ulcer? YesNo Attacks of gallstone colic? YesNo Stroke? YesNo Epilepsy or other neurological illness? YesNo Diabetes mellitus? YesNo Any disturbance of kidney or bladder? YesNo Diarrhoea, colitis, constipation or piles? YesNo Thyroid treatment? YesNo Severe depression or other nervous disorder? YesNo Gout? YesNo Allergy to milk? YesNo Any other serious illness? YesNo Are you taking any medically prescribed drugs, pills, tablets or other medication or having medical treatment in any form? YesNo Any disturbance of liver? YesNo Have you attended any doctor in the past 12 months? YesNo Have you ever had or been recommended to have an operation? YesNo In the past 6 months, what has been your average daily consumption of alcohol and/or tobacco (required) Are you? sedentarymoderately activevery active ****************** WOMEN ONLY ****************** Are you pregnant? YesNoN/A Are you intending to become pregnant in the next 3 months? YesNoN/A Have you given birth in the last 3 months, or miscarried? YesNoN/A Are your menstrual periods regular? YesNoN/A Are you using a contraceptive cap? YesNoN/A If answered YES to any of the above please detail extra information here I declare that the above answers are true, that I have not omitted any material information and that I authorise the release of the findings of the questionnaire to Waistaway Ltd, Howard Foundation Research Ltd. and the supervising pharmacy. (See T&Cs)? You must select Yes to participate. YesNo I am happy to be contacted by: emailDirect mailText messageTelephone I am happy to be contacted about: Ongoing Support (essential)News and Updates