Weight Management Clinic – Questionnaire – Galway Bay Medical Centre

Pre-Appointment Questionnaire

Injections can be used as part of our weight management programme. These may be used as an adjunct to a reduced calorie diet and increased physical activity.

We need to determine if you are suitable for these medicines prior to your appointment, so we would appreciate if you could answer the following questions:

Personal Details

First Name(s)(Required)

Surname(s)(Required)

Date of Birth(Required)

Email(Required)

General Information

Do you have a needle phobia?

Do you have a history of allergies to any medications?

Are you taking hormonal contraception?

Are you currently pregnant or trying to become pregnant?

Are you breastfeeding?

Medical Conditions

Do you have any of the following conditions?

Type 1 Diabetes

Type 2 Diabetes

Any bowel or gut problems

Gastro-oesophageal reflux disease (GORD)

Kidney problems

Liver problems

Eye problems associated with your diabetes (retinopathy)

Mental health condition eg. depression

Personal or family history of thyroid cancer

Personal or family history or Multiple Endocrine Neoplasia (MEN) type 2

Do you have any of the following risk factors for pancreatitis?

Gallstones

History of alcohol overuse

High triglycerides (lipids)

Medications

Are you on any of the following medications to treat diabetes:

DPP-4 inhibitors (gliptins) for example:

- Sitagliptin (Januvia or Janumet)

- Linagliptin (Trajenta or Jentadueto)

- Saxagliptin (Onglyza)

Sulfonylureas

Insulin

Please list all medications that you are currently taking and the doses:

Lifestyle

Do you smoke?

Do you drink Alcohol?

If so, please state the amount below:

Alcohol intake:

Are you currently employed/self-employed?

If so, please state your occupation below:

Occupation

Do you do shift work?

Other

Family History of note:

Please list any specialists involved in your current care:

Herbal Medication or Supplements:

Any scheduled surgery or procedure involving sedation in the future?

Wegovy may increase the risk of aspiration from deep sedation or general anaesthesia.

Have you tried any other weight loss methods to date?

If so, please elaborate below:

Alcohol intake:

What do you hope to achieve from using Wegovy? Any other information you may feel is relevant?

Are you a robot?

(091) 530054

info@GalwayBayMedicalCentre.ie

Weight Management Clinic – Questionnaire