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