Doctor Questionnaire

Please enable JavaScript in your browser to complete this form.

PERSONAL DETAILS - Step 1 of 4

Full name *

Date of birth *

Gender *

Address *

Phone number *

Email address *

Medicare number and reference number *

Emergency contact name and phone number *

Current weight and height *

Goal weight *

Have you been diagnosed with any of the following: Type 1 or Type 2 diabetes, heart disease, kidney disease, liver disease, thyroid conditions, eating disorders, depression or anxiety, any other medical conditions (please specify) *

Are you currently taking any prescription medications? If yes please list them *

Do you have any known allergies to medications? *

Have you previously used GLP-1 medications such as Ozempic, Wegovy, Mounjaro or similar? If yes what dose and for how long? *

Have you experienced any side effects from weight loss medications previously? *

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

Do you have a current GP? If yes please provide their name and clinic *

Have you had blood tests in the last 12 months? If yes please upload results (optional)

Click or drag files to this area to upload. You can upload up to 4 files.

How would you describe your current diet? *

How much water do you drink per day?

How many hours of sleep do you get per night?

Do you smoke or consume alcohol regularly?

I consent to WeightLoss Australia and its affiliated medical practitioners collecting and storing my personal and medical information for the purpose of assessing my eligibility and managing my treatment program.

I authorise WeightLoss Australia and UHD BioHealth to liaise with our compounding pharmacy on my behalf to organise and dispense my prescribed medication once approved by a doctor.

I understand that all treatments are subject to medical assessment and doctor approval and that no medication will be dispensed without a valid prescription.

I understand that my payment is held securely and will only be processed upon doctor approval of my program. If my program is not approved I will receive a full refund.

I confirm that all information provided in this form is accurate and complete to the best of my knowledge.

I have read and agree to the WeightLoss Australia Terms and Conditions and Privacy Policy.

Typed full name as signature *

Date of submission

All treatments and programs are subject to medical assessment and doctor approval.

Doctor Questionnaire

© Weightloss Australia