Weight Loss Treatment
Assessment Form

Please complete this weight loss treatment assessment form so we can establish if this type of treatment is suitable for you...

First NameLast NamePhoneEmail AddressEthnicityHeightWeight

Medical History

Do you currently take any medication?Yes - I'm taking medicationNo - I'm not taking any medicationDo you have any of the following medical conditions?DiabetesPre-DiabetesHigh Blood Pressure (Hypertension)High CholesterolObstructive Sleep Apnoea (OSA)Are you currently using or have you previously used any weight loss medications?YesNoDo you have any allergies?YesNoAre you currently pregnant, trying to conceive or breastfeeding?YesNoHave you ever been diagnosed with an eating disorder or show symptoms of one?(Such as Anorexia Nervosa or Bulimia)YesNoAre you currently registered with a GP practice (UK)?YesNo

Terms & Conditions

I have read, understand and agree to Re-Vive Aesthetics’ terms and conditions and privacy notice.Our prescribed weight loss treatments and medications are only effective alongside a healthy lifestyle, such as a low-calorie diet and regular physical activity. If I don’t make these changes alongside my medication and treatment plan, I may not lose weight or may lose less than expected and have to stop treatment.I confirm that this medication and weight loss treatment is for my personal use only. I have answered all of the above questions myself and honestly. I understand the possible side effects and effectiveness of the medication and treatments provided by my assigned doctor.

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The Medical Centre, 1 Woodland Drive, Great Alne, B49 6FP
01789330518 | info@reviveskin.clinic

Weight Loss Treatment Assessment Form

Medical History

Terms & Conditions

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Weight Loss Treatment
Assessment Form