Medical Questionnaire

Patient Profile

Full Name

Email Address

Phone Number

Weight (kg)

Height (cm)

Pregnancy & Breastfeeding

Are you currently pregnant, breastfeeding, or planning to become pregnant?

Yes No

Blood Pressure History

Have you ever been diagnosed with high blood pressure?

Yes No Unsure

Usual Blood Pressure

Select your typical range:

Medical Conditions

Do you have any of the following medical conditions?

Thyroid Disease Pancreatitis Kidney Disease Diabetes Type 1 Diabetes Type 2 Heart Disease Mental Health Issues None of the Above

Other Medical Conditions

Please list any other conditions (or type 'None'):

Allergies

List any medication or food allergies (or type 'None'):

Current Medications

Do you take any of the following medications? (Select all that apply)

Insulin

Sulfonylureas

Glimepiride (Amaryl), Glipizide (Glucotrol and Glucotrol XL), Glyburide (Micronase, Glynase, Diabeta), Gliclazide, Gilbenclamide, Tolbutamide

DPP-4 inhibitors

Sitagliptin, Saxagliptin, Linagliptin, Alogliptin

SGLT-2 inhibitors

Empagliflozin, Dapagliflozin, Canagliflozin, Ertugliflozin

Other blood thinners taken for any of the following conditions

Von Willebrand Disease, Antiphospholipid Syndrome (APS), Disseminated Intravascular Coagulation (DIC), Factor V Leiden, Protein C Deficiency, Protein S Deficiency

Others

Warfarin, Lithium, Digoxin, Theophylin, Acenocoumarol, Amiodarone, Clozapine, Flecanide, Insulin

None of the above

Smoking & Vaping

Yes No Prefer not to say

Alcohol Consumption

Units per week:

Sleep Habits

Average hours per night:

Physical Activity

Hours of activity per week:

Caffeine Intake

Cups of tea/coffee per day:

Hydration

Glasses of water per day:

Weight Loss Treatments

Are you currently using any treatments?

Side Effects

Have you experienced side effects from treatment?

Transferring Provider?

Upload previous prescription if applicable (Optional).

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Ethnic Background

Used for clinical BMI assessment.

Front Photo

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Side Photo

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Terms & Conditions

By submitting this form, you declare that the information provided is accurate. False information may lead to adverse health effects. Your data will be processed in accordance with our privacy policy and used solely for medical assessment purposes.

I accept the terms and conditions and confirm my answers are truthful.

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✓ All sections completed

Medical Questionnaire

Patient Profile

Pregnancy & Breastfeeding

Blood Pressure History

Usual Blood Pressure

Medical Conditions

Other Medical Conditions

Allergies

Current Medications

Smoking & Vaping

Alcohol Consumption

Sleep Habits

Physical Activity

Caffeine Intake

Hydration

Weight Loss Treatments

Side Effects

Transferring Provider?

Ethnic Background

Front Photo

Side Photo

Terms & Conditions

Ready to Submit

Processing Submission

Pharmacy: Lumos HC Ltd

Company No. 16381145

Superintendent Pharmacist: Sri Kantamneni

Registration number: 2068584

Pharmacy GPhC Registration: 9012954

Tel: 01452 595022