Answer a few quick questions to see your eligible treatments
Returning Patient?Log in to reorder using your saved assessment.
WEIGHT ASSESSMENT
Do you suffer from prediabetes, diabetes, heart disease, high blood pressure, high cholesterol or obstructive sleep apnoea?
YesNo
ABOUT YOU
Are you between the ages of 18 and 74?
YesNo
If you have type 2 diabetes, are you on any injections or tablets to control your blood sugar, other than metformin?
YesNo
Have you experienced an allergic reaction to Wegovy, Mounjaro, Semaglutide, Saxenda or Liraglutide before?
YesNo
Have you ever suffered with an eating disorder?
YesNo
Are you pregnant, breastfeeding, or trying to conceive?
YesNo
Have you been diagnosed with or had surgery for any of the following?
Acromegaly or any growth hormone problem
Chronic Malabsorption Syndrome
Cushings Syndrome
Gallbladder, Bile duct or Pancreas disease
Gastric surgery (bariatric surgery)
Heart Failure
Hypoglycaemia
Kidney Disease
Liver Disease
Pancreatitis
Severe gastrointestinal disease (e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease)
Type 1 Diabetes
YesNo
Do you have a personal or family history of Medullary Thyroid Cancer, Thyroid cancer or Multiple Endocrine Neoplasia 2 (MEN2) syndrome?
YesNo
MEDICATIONS
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
YesNo
Are you taking steroids or medication to treat your thyroid?
YesNo
Have you taken injectable weight loss medication in the last 4 weeks?
YesNo
Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you:
This is your first order of with PillSorted and you do not order the starter dose
Your last order with PillSorted was more than 8 weeks ago and you wish to order a higher strength
YesNo
ADDITIONAL NOTES FOR THE PRESCRIBER
Anything you'd like the prescriber to know?Include any personal circumstances, like upcoming travel, that may affect your treatment.
AGREEMENT
Do you agree to the following?
You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
YesNo
Do you understand that GLP-1 injectable weight-loss medication (such as Mounjaro and Wegovy) may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment?
YesNo
Do you understand that this medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?
YesNo
Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?
YesNo
Do you understand that injectable weight loss medications should not be used with other weight loss medications?
YesNo
Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?
YesNo
Both weight loss and injectable weight loss treatment has been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental health issues), do you understand you should stop treatment and speak to your doctor?
YesNo
Estimated time to complete2 minutes
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Your Pharmacist
Pharmacist
Zeinab ArdeshirSuperintendent Pharmacist GPhC (2075730)