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1.1 – Personal Details
Title
Select
Mr.
Mrs.
Ms.
Dr.
Prof.
Preferred Name
First Name
Middle Name
Last Name
Gender
Select
Female
Male
Other
Date of Birth
1.2 – Contact Details
Email
Phone Number
Address
1.3 – Medicare Details
I don't have Medicare
Medicare Card No
Individual Reference No
Expiry Month / Year
Medical Weight Management: Eligibility Questionnaire
Body Metrics
What is your height?
What is your weight?
Your BMI
Basic Eligibility
Are you 18 years old or older?
Yes
No
Medical Weight Management: Do you have any of the following health conditions? (Select all that apply)
Type 2 Diabetes
High blood pressure
Sleep apnoea
High cholesterol or triglycerides
Fatty liver disease
None of the above
Have you previously tried a medically supervised weight management programme?
Yes
No
Are you currently pregnant, planning to become pregnant, or breastfeeding?
Yes
No
Do you or any close blood relatives have a history of medullary thyroid cancer or a condition called MEN2 (Multiple Endocrine Neoplasia type 2)?
Yes
No
Have you ever been diagnosed with or treated for pancreatitis (inflammation of the pancreas)?
Yes
No
Medical Weight Management: Do you have any of the following conditions? (Select all that apply)
Type 1 Diabetes
An eating disorder (past or present)
Severe kidney disease
Severe liver disease
Stomach emptying problems (gastroparesis)
None of the above
Are you currently taking, or have you recently taken, any prescription medications?
Yes
No
Please provide more information:
Have you had weight loss surgery in the past?
Yes
No
Please provide more information:
Medical Weight Management: Standardised Health Assessment
Weight History and Goals
Around what age did you first notice significant weight gain?
Under 18
18–25
26–35
36–45
46–55
Over 55
What do you think has mainly contributed to your weight gain?
Diet and eating habits
Low physical activity
A health condition or hormonal issue
Stress or mental health
A medication side effect
Other / Not sure
What is your main goal for joining this programme?
Lose weight
Improve a health condition (e.g., diabetes, blood pressure)
Feel more energetic and mobile
Support fertility or hormonal health
Improve my overall health
Dietary Behaviour
How would you describe your current eating habits?
Regular meals (roughly 3 per day)
Frequent snacking between meals
Episodes of eating large amounts in one go
Often skipping meals
Eating in response to stress or emotions
No particular pattern
Do you currently follow a specific diet or eating plan?
No specific plan
Low carbohydrate or ketogenic
Intermittent fasting
Vegan or vegetarian
A medically prescribed diet
Other
Physical Activity
IPAQ-SF – Over the past week, how many days did you do moderate physical activity for at least 30 minutes?
0 days
1–2 days
3–4 days
5–6 days
7 days
IPAQ-SF – Over the past week, how many days did you do vigorous physical activity for at least 20 minutes?
0 days
1–2 days
3–4 days
5 or more days
Mood and Wellbeing
PHQ-2 – Over the past 2 weeks, how often have you had little interest or pleasure in doing things you normally enjoy?
None
A little bit
Most of the time
All of the time
PHQ-2 – Over the past 2 weeks, how often have you felt down, depressed, or hopeless?
None
A little bit
Most of the time
All of the time
GAD-2 – Over the past 2 weeks, how often have you felt nervous, anxious, or on edge?
None
A little bit
Most of the time
All of the time
GAD-2 – Over the past 2 weeks, how often have you been unable to stop or control worrying?
None
A little bit
Most of the time
All of the time
Alcohol Use
AUDIT-C – How often do you have a drink containing alcohol?
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
AUDIT-C – On a typical drinking day, how many standard drinks do you consume?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
AUDIT-C – How often do you have 6 or more standard drinks on a single occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
4.1 – Confirmation
Confirm you are ready to finalise and submit this form to your practitioner.
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