Skip to content

Pharmalogic Chemists

Chemists in the North West

info@pharmalogic.co.ukContact Us

Home
About
Our Services
Health Advice
Careers
Weight Management
Contact Us

Home
About
Our Services
Health Advice
Careers
Weight Management
Contact Us

Section 1/8

Personal Information

Photo ID

I understand and accept Terms & Conditions*

Section 2/8

Patient History

What are your main reasons for wanting to lose weight?

(Select all that apply)

Improve physical health Feel more confident or comfortable in my body Reduce risk of chronic conditions (e.g., diabetes, hypertension) Improve mental wellbeing Other (please specify)

How long have you been trying to lose weight?

Less than 6 months 6-12 months 1-3 years More than 3 years

What have you tried previously?

Diet changes Increased physical activity Prescription medication Commercial or NHS weight-loss programmes Bariatric surgery Other (please specify)

Section 3/8

Weight, Height & BMI

Please provide your current measurements.

Upload Scale Reading

Have you been told your weight or BMI puts you at increased health risk?

Yes No Not sure

Section 4/8

G-1 Medication History

Tell us about your experience with GLP-1 medications.

Have you taken GLP-1 medications for weight loss before?

Yes No

Which medication(s) have you used? (Select all that apply)

Mounjaro Wegovy Saxenda Other (please specify) Not applicable

Which medication did you last take between Mounjaro and Wegovy?

Mounjaro Wegovy

When was your last dose?

What dose did you last inject?

2.5 mg 5 mg 7.5 mg 10 mg 12.5 mg 15 mg

0.25 mg 0.5 mg 1 mg 1.7 mg 2.4 mg

Do you wish to continue this treatment?

Yes No Unsure

How would you describe your experience with the medication?

Very positive – minimal/no side effects Mostly positive – side effects resolved Neutral Negative – ongoing side effects Other (please specify)

Section 5/8

Medical History

Please provide your medical history.

Have you ever been diagnosed with diabetes?

Yes – Prediabetes Yes – Type 1 Yes – Type 2 No

Have you been diagnosed with hypertension?

Yes No

Do you currently have (or are being investigated for) any of the following? (tick all that apply)

Pancreatitis Gallbladder disease or gallstones Thyroid cancer (or family history of MTC or MEN2) Severe digestive/gastrointestinal issues (e.g. gastroparesis) Diabetic retinopathy None of the above

Mental Health History – Have you been diagnosed with or currently being treated for:

Depression Anxiety Eating disorder Other psychiatric conditions No mental health diagnoses

Have you had surgery in the last 12 months?

Yes (please specify) No

Other current or past health conditions?

Yes (please specify) No

Have you been diagnosed with Polycystic Ovarian Syndrome (PCOS)?

Yes No

Have you ever been diagnosed with heart failure?

Yes No

Section 6/8

Medications & Allergies

Are you currently taking any prescription medications, supplements, or vitamins?

Yes (please list below) No

Are you currently taking any of the following? (Select all that apply)

Warfarin Digoxin Oral contraceptive pill Medications known to cause weight gain Other Weight Loss Medications None

Are you allergic to tirzepatide or any excipients in Mounjaro?

Yes (please specify below) No

Any other allergies?

Yes (please specify below) No

If eligible, what is your treatment preference?

Section 7/8

Reproductive Health

Information for female patients regarding pregnancy and contraception.

Are you currently:

Pregnant Breastfeeding Trying to conceive None of the above

Are you using contraception?

Oral contraceptive pill (Use barrier method for 4 weeks after initiation or dose change) Long-acting contraceptive (e.g. implant, coil, injection) Condoms or barrier methods No Not applicable

This section is not applicable for male patients.

Section 8/8

Consent & Awareness

Final consent and acknowledgment section.

Are you aware of the potential side effects of Mounjaro (e.g., nausea, vomiting, dehydration, pancreatitis, gallstones)?

Yes No

Do you agree to seek medical advice if you experience serious or concerning side effects?

Yes No

Do you understand the importance of using only licensed and regulated pharmacies for G-1 medications?

Yes No

Confirm the following (all boxes must be checked to proceed):

I confirm the information I have provided is accurate to the best of my knowledge.

I consent to contact and a clinical review prior to any prescription being issued.

I understand my prescription may not be approved without verification of my weight, BMI, and health status.

I have read and understood the counselling information about treatment, risks, and my responsibilities.

I consent to G-1 Nutrition accessing my National Care Service Record for clinical assessment.

E-Signature

Drawn signature captured and will be submitted.

Signature Date

—

✓

Assessment Submitted Successfully!

Thank you for submitting your assessment. A clinician will review your application and be in touch with next steps.

About Us

Founded in 2009, Pharmalogic has developed and specialised in becoming the first healthcare group to establish a dedicated care home service, alongside our independent, family-run, community chemists throughout the NorthWest region.

Our Superintendent Pharmacist is Haroon Amanji (Reg. No. 2070534)

Quick Links

Home
About
Our Services
Health Advice
Careers
Complaints
Contact Us

Our Services

Prescriptions
Pharmacy First
Ear Clinic
Our Care Home Service

Head Office

Address
464 Ranglet Road
Walton Summit Centre
Preston
PR5 8AR
Tel
+44 (0) 1772 620526
Fax
+44 (0) 1772 697328
Email
info@pharmalogic.co.uk

All Rights reserved. MDS Healthcare Limited. Copyright 2020 © 464 Ranglet Road, Walton Summit Centre, Preston PR5 8AR Tel: 01772 620526

All Rights reserved. MDS Healthcare Limited. Copyright 2024© 464 Ranglet Road, Walton Summit Centre, Preston PR5 8AR Tel: 01772 620526

Covid-19 Advice - To read the national local advice about Coronavirus, please click the button

LATEST INFORMATION