Eligibility Quiz

WegovyMounjaroSaxendaOther

MaleFemaleNon-binaryPrefer not to say

White British, Irish (other white backgroundsincluding, Gypsy or Irish traveller)Mixed and multiple backgrounds, White and black Caribbean,White and black African white and black Asian, and other mixed or multiplebackgrounds.IndianPakistaniBangladeshiChineseBlack AfricanBlack CaribbeanOther backgrounds,(including any other Asian backgrounds, any other black backgrounds, Arab or any other ethnic group)

Your blood pressure can be checked at many local pharmacies as well as your Doctors surgery.

Liver, kidney or heart failurePancreatitisMultiple endocrine neoplasia type 2CancerType 1 diabetes ordiabetic retinopathyPersonal or family history of medullary thyroid cancerHistory of gall bladder problemsHistory of Inflammatory bowel disease or gastroparesisNone of the above

InsulinSulfonylureas e.g., gliclazide, metforminGLP-1 receptor agonists e.g.,Victoza, Saxenda

Improving my overall healthLooking and feeling betterBecoming more activeImproving my mood or mental wellbeingImproving my sleep or energy levelsMusculo-skeletal reasons such as chronic back knee or hip painOther or avoiding or managing a specific health condition – specify which below

None1-2 hours moderate intensity exercise each week – any activity which gets you outof breath i.e., brisk walking, riding a bike, water aerobics2-3 hours moderate intensity exercise each week – any activitywhich gets you out of breath i.e., brisk walking, riding a bike, water aerobics1-2 hours vigorous intensity exercise each week i.e., running,swimming fast, sports, skipping rope.More than 4 hours moderate or vigorous intensity exercise.

I want to minimise the risk of common side effects, e.g., nauseaI want to maximise my resultsI want an easy and convenient optionI want something that helps me stay consistentNone of the above

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code

Declarations

Please read the following Declarations carefully and select to agree.

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Eligibility Quiz

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Your current health