Quiz – Weight Loss

Weight Loss
Pre-consultation Assessment

Please complete this short quiz to book in your initial consultation. It will only take 5 minutes and will help our doctors better understand your unique circumstances.

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Name
Current Address
You will receive a confirmation to this email address.
Date of Birth
Do you have a Medicare number or IHI?
What was your sex at birth?
If female, are you pregnant or breastfeeding?
Your practitioner may request photos or a video consult if they deem necessary.
Just to be cautious, do you suffer from any of the following?
Do you use any recreational drugs?
How often do you exercise?
Do you smoke or vape?
Do you drink alcohol?
How many coffees or other caffeinated beverages do you drink per day?
How would you rate your average night's sleep?
How would you rate your mood recently?
A few questions about your specific condition – only a health practitioner will see this information.
What is your ethnic background?
What is your main reason for wanting to lose weight?
Have you ever tried losing weight before?
If yes, what weight loss methods have you tried?
How long has it been since you have been at your ideal weight?
How would you rate your current diet?
Do you currently follow a diet?
How many times a week do you eat out?
How many times per week do you get takeaway?
How often do you snack?
How many times per week do you eat processed foods?
How often do you eat fruit or vegetables?
How often do you drink soft drinks?
How much moderate physical activity do you do per week?
Does your weight interfere with your ability to exercise?
Have you ever been diagnosed with any of the following medical conditions?
Have you ever had any issues with any of the following?
Have any of your immediate family members ever had issues with any of the following?
Are you currently taking any of the below medications?
Have you ever had any of the following surgeries?
Have you ever had diabetes?
Is there any history of diabetes in your family?
Is there any history of heart disease in your family?
Do you ever make yourself sick (vomit) because you feel uncomfortably full or you are worried you have over-eaten?
Do you ever worry you have lost control over how much you eat?
Would you say food dominates your life?
Has your weight affected your ability to socialise or engage with friends?
Does your weight interfere with activities/tasks/family responsibilities?
Do you believe your weight is negatively affecting your health?
To help the doctor determine the best treatment option for you, let your doctor know if you are open to using tablets or injections?
How important is this weight loss journey for you?
You’re almost done.
Do you confirm that the information you have given is true and accurate, and is solely for yourself and if prescribed a medication, you will review the information supplied regarding the medication and side effects?