Client Health Questionnaire for Personalized Insights

Transform Lives with Doctor Led Health Coaching online

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About Us
Services
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We want to know more about you ?

Your First Name

Your Email Address*

How tall are you ?*

How much do you weigh?*

What is your motivation for losing weight?*

What would you like help with ?

Do you have any of the following medical conditions ?

Chronic Kidney Disease

Pre-Diabetes

Diabetes

Fatty Liver Disease

Polycystic Ovaries Syndromes (PCOS)

High Cholesterol

Obstructive Sleep Apnoea

None of the Above

Which ethnicity best describes you ?

White

Black, Black British, Black African or Black Carribean

Asian or Asian British

Mixed or Mutiple Ethnic Groups

Other

What is your date of birth ?*

What sex were you assigned at birth ?*

Are you pregnant, breast feeding or possibly pregnant ?

Are you taking contraception if so which contraception ?*

What medication are you taking ?

Are you currently taking, or have you previously been, prescribed a GLP-1 medication?

Yes

Do any of the following the statements apply to you ?

You think you're too fat, whenover think you're too thin

You sometimes make yourself sick after eating as you feel full

You have taken laxatives, diuretics or other medications to reduce your weight

None of Above

Do you suffer with an eating disoder, ? e.g Anorexia Nervousa, Bulimia, Binge eating disorders

Yes

Please provide 3 dates and times of availability for an appointment. ? We will contact you in 3-5 business days anappointment confirmation and invoice.

Dr Williams would like to know as much information about you, so she can tailor her appointment to you.

Health

Empowering patients for better health outcomes.

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contact@ihealselfonline.com

+441234567890

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