Weightloss Consultation

Your Name (required)

Your Email (required)

Your Date Of Birth (required)

Mobile Phone Number (required)

Your Height(m) (required)

Your Weight(kg) (required)

Individual Readiness for Change Questionnaire

A. Do you feel motivated to lose excess body fat at this time?
Not at all motivatedslightly motivatedSomewhat motivatedQuite MotivatedExtremely motivated
B. How motivated are you to change your eating habits at this time?
Not at all motivatedslightly motivatedSomewhat motivatedQuite MotivatedExtremely motivated
C. How motivated are you to increase your physical activity at this time?
Not at all motivatedslightly motivatedSomewhat motivatedQuite MotivatedExtremely motivated
D. How motivated are you to try new strategies/techniques for changing your dietary, physical activity and other health related behaviours at this time?
Not at all motivatedslightly motivatedSomewhat motivatedQuite MotivatedExtremely motivated
E. People who want to achieve long-term weight control need to spend time every day trying to plan for healthy meals, physical activity and behaviour change. How confident are you that you can devote time and effort, now and over the next few months?
Not at all motivatedslightly motivatedSomewhat motivatedQuite MotivatedExtremely motivated
F. How confident are you that you will be able to record everything you eat and drink and your movement, most days of the week for 2-4 weeks?
Not at all motivatedslightly motivatedSomewhat motivatedQuite MotivatedExtremely motivated
G. How satisfied would you be if you achieved a 10% weight loss that significantly improved your health and quality of life?
Not at all motivatedslightly motivatedSomewhat motivatedQuite MotivatedExtremely motivated

Any other Comments

Medical Questionnaire
Are you Pregnant or Breast Feeding?
YesNo
Are you diabetic?
YesNo
Do you have a history of thyroid cancer?
YesNo
Do you have a history of pancreatitis?
YesNo
Do you suffer from heptatic impairment?
YesNo
Do you suffer from renal impairment?
YesNo
Do you suffer from congestive heart conditions?
YesNo
Do you suffer from hypersensitivity to Liraglutide?
YesNo

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