BMI Calculator Example Online Medical Consultation with hand-coded BMI Calculator Example of online consultation coded for client in United Kingdom Step 1 of 6 16% Client InfoName* First Last Email* Phone Number* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What is your date of birth?* DD slash MM slash YYYY Preferred Method of Contact* Phone Email About YouDo you confirm that* Select All You consent to receiving remote/online consultation You will answer all questions honestly and understand that it is an offence to provide false information You are using the service on your own behalf and of your own free will Any treatment/medical advice provided is for you only and based on the information you have provided You Consent for us to carry out an automated ID and age verification check during this process. Please check box to confirmWhat is your height?* Metric Imperial Please select Metric or ImperialMeters*meters0 m1 m2 mCm*centimeters0 cm1 cm2 cm3 cm4 cm5 cm6 cm7 cm8 cm9 cm10 cm11 cm12 cm13 cm14 cm15 cm16 cm17 cm18 cm19 cm20 cm21 cm22 cm23 cm24 cm25 cm26 cm27 cm28 cm29 cm30 cm31 cm32 cm33 cm34 cm35 cm36 cm37 cm38 cm39 cm40 cm41 cm42 cm43 cm44 cm45 cm46 cm47 cm48 cm49 cm50 cm51 cm52 cm53 cm54 cm55 cm56 cm57 cm58 cm59 cm60 cm61 cm62 cm63 cm64 cm65 cm66 cm67 cm68 cm69 cm70 cm71 cm72 cm73 cm74 cm75 cm76 cm77 cm78 cm79 cm80 cm81 cm82 cm83 cm84 cm85 cm86 cm87 cm88 cm89 cm90 cm91 cm92 cm93 cm94 cm95 cm96 cm97 cm98 cm99 cmFeet*feet0 ft.1 ft.2 ft.3 ft.4 ft.5 ft.6 ft.7 ft.8 ft.Inches*inches0 in1 in2 in3 in4 in5 in6 in7 in8 in9 in10 in11 inHiddenHeight in InchesWhat is your weight* Metric Imperial Please select Metric or ImperialWeight*kg41 kg42 kg43 kg44 kg45 kg46 kg47 kg48 kg49 kg50 kg51 kg52 kg53 kg54 kg55 kg56 kg57 kg58 kg59 kg60 kg61 kg62 kg63 kg64 kg65 kg66 kg67 kg68 kg69 kg70 kg71 kg72 kg73 kg74 kg75 kg76 kg77 kg78 kg79 kg80 kg81 kg82 kg83 kg84 kg85 kg86 kg87 kg88 kg89 kg90 kg91 kg92 kg93 kg94 kg95 kg96 kg97 kg98 kg99 kg100 kg101 kg102 kg103 kg104 kg105 kg106 kg107 kg108 kg109 kg110 kg111 kg112 kg113 kg114 kg115 kg116 kg117 kg118 kg119 kg120 kg121 kg122 kg123 kg124 kg125 kg126 kg127 kg128 kg129 kg130 kg131 kg132 kg133 kg134 kg135 kg136 kg137 kg138 kg139 kg140 kg141 kg142 kg143 kg144 kg145 kg146 kg147 kg148 kg149 kg150 kg151 kg152 kg153 kg154 kg155 kg156 kg157 kg158 kg159 kg160 kg161 kg162 kg163 kg164 kg165 kg166 kg167 kg168 kg169 kg170 kg171 kg172 kg173 kg174 kg175 kg176 kg177 kg178 kg179 kg180 kg181 kg182 kg183 kg184 kg185 kg186 kg187 kg188 kg189 kg190 kg191 kg192 kg193 kg194 kg195 kg196 kg197 kg198 kg199 kg200 kg201 kg202 kg203 kg204 kg205 kg206 kg207 kg208 kg209 kg210 kg211 kg212 kg213 kg214 kg215 kg216 kg217 kg218 kg219 kg220 kg221 kg222 kg223 kg224 kg225 kg226 kg227 kg228 kg229 kg230 kg231 kg232 kg233 kg234 kg235 kg236 kg237 kg238 kg239 kg240 kg241 kg242 kg243 kg244 kg245 kg246 kg247 kg248 kg249 kg250 kg251 kg252 kg253 kg254 kg255 kg256 kg257 kg258 kg259 kg260 kg261 kg262 kg263 kg264 kg265 kg266 kg267 kg268 kg269 kg270 kg271 kg272 kg273 kg274 kg275 kg276 kg277 kg278 kg279 kg280 kg281 kg282 kg283 kg284 kg285 kg286 kg287 kg288 kg289 kg290 kg291 kg292 kg293 kg294 kg295 kg296 kg297 kg298 kg299 kg300 kgStones*stones1 st.2 st.3 st.4 st.5 st.6 st.7 st.8 st.9 st.10 st.11 st.12 st.13 st.14 st.15 st.16 st.17 st.18 st.19 st.20 st.21 st.22 st.23 st.24 st.25 st.26 st.27 st.28 st.29 st.30 st.31 st.32 st.33 st.34 st.35 st.36 st.37 st.38 st.39 st.40 st.41 st.42 st.43 st.44 st.45 st.46 st.47 st.48 st.49 st.50 st.Pounds*Pound0 lb1 lb2 lb3 lb4 lb5 lb6 lb7 lb8 lb9 lb10 lb11 lb12 lb13 lbHiddenWeight in lbsHiddenBMI LogicBMI We're sorry, but your BMI is too low for this treatment. Your online consultation has ended.Your BMI is sufficient for treatment. Please click "Next" button to continue your online consultation.Hidden Have you had your blood pressure checked in the last 12 months? Yes No You will need to have your blood pressure checked before you start treatment, and have it checked again at least every 12 months if you continue taking it. Click here to find out more about blood pressure testing and how you can have yours checked.If Yes* Options: Low - 90/60 Normal – Between 90/60 and 139/89 High – 140/90 or Above Do you have an allergy to any of the following? Liraglutide Semaglutide Disodium phosphate dihydrate Propylene glycol Phenol Hydrochloric acid Sodium hydroxide Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available. If you have been prescribed the medicine already or believe you should be allowed to take the medicine, please contact us. Have you, or anyone in your family ever had cancer of the thyroid or adrenal gland?* Yes No Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available.Do you have a history of heart problems?* Yes No For example: abnormal heart rhythms, heart disease, heart attack, heart failure etc.Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available.Do you have an inflamed gallbladder or gallstones?* Yes No Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available.Do you suffer from any SEVERE gastro-intestinal problems?* Yes No For example: inflammatory bowel disease or gastroparesis etc?Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available.Do you have a history of pancreatitis?* Yes No Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available.Do you have severe renal (kidney) disease or impairment?* Yes No Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available.Do you have any disorders of the liver?* Yes No For example: hepatitis, fatty liver, alcohol liver disease etc.Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available.Do you have any disorders of the thyroid?* Yes No For example: goiter, Graves' disease, hypothyroid, hyperthyroid etc.Losing weight and keeping it off can be a struggle with an underactive thyroid. Please ensure you have regular bloods taken with your GP to ensure you are taking the correct dose of thyroxine.Do you have any form of diabetes?* Yes No Please give details and list any medication you are taking*Do you have any mental health problems?* Yes No Please give details*Are you taking any other medication not already listed above? (Prescribed, over-the-counter or herbal)* Yes No Please give details*Is there anything else about your general health you think may be relevant to your treatment?* Yes No Please give details and list any medication you are taking*Additional ChargesTotal $0.00 About Your LifestyleDo you drink alcohol?* Yes No How many units per week?*1-56-1011-1516-2021-2526-3031+ Click here to calculate how many units you drinkHow many glasses of water do you drink each day?*None1-23-45-67-89+It is very important to stay hydrated when taking this medication in order to reduce potential constipation.How much exercise / activity do you do each week?*Very LittleOne HourTwo to Three HoursMore than 3 HoursThis doesn't have to be set time in the gym, it can be ANY activity that gets your heart pumping. (Current guidelines recommend 150 minutes of moderate aerobic activity or 75 minutes vigorous activity per week)How many calories do you think you consume daily?*Calories ConsumedLess than 10001001-15001501-20002001-2500More than 2500How many times a week do you eat fast food or takeaways?*01-34-67-9More than 9Do you regularly eat crisps, biscuits, chocolate or cakes?*YesNoDo you have, or think you have an eating disorder? This could be Anorexia, bulimia, etc.* Yes No Please give details*About Your LifestyleWhy do you want to lose weight?*What have you already tried to help you lose weight? Nothing Diet Meal Replacement Program Increased Exercise Weight Loss Medication Hypnosis Surgery Went to see GP Other Have you used Saxenda, Ozempic or Rybelsus before? (Tick all that apply)* Saxenda Ozempic Rybelsus None of the above Are you comfortable with your injection technique / dosing schedule?* Yes No What dose are you currently taking?* How long have you been using it?*Less than 6 Months6-12 MonthsMore than 12 MonthsHave you experienced any undesirable side effects that you find hard to tolerate?* Yes No Please give details*Are you currently taking any other weight loss medications? e.g. Xenical, Alli, Orlistat, Mysimba, Phentermine etc.* Yes No Your response means that this is not a safe treatment for you, we therefore cannot prescribe it. Please consult your own doctor to discuss any other treatment options available. Declaration & ConsentI confirm that* Select All I am over the age of 18 This prescription request is for my own personal use I have answered all questions truthfully, and I acknowledge that incorrect information can be dangerous I understand you take my answers in good faith, and base your prescribing decisions accordingly I will inform my GP about this treatment I will read the patient information leaflet supplied with any medication you prescribe I must combine treatment with a reduced calorie diet, and increased physical activity for best results I have been given no guarantees of weight loss using any of these treatment I understand that if I have not lost 5% of my initial body weight within 12 weeks of being on the licensed dose, I must discontinue treatment I agree to your terms and conditions and give my consent to treatment if I am found to be suitable to have it prescribed Digital Signature Required*NameThis field is for validation purposes and should be left unchanged.
