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Prosper Healthcare

Weight Management – Restart consultation

Answer the eligibility, medicine and safety questions so the clinical team can review your request and contact you about next steps.

What happens next

After you submit, your answers are reviewed inside the secure CRM and we contact you about next steps.

How this questionnaire works

Step 1 Complete the questionnaire.
Step 2 We review your answers.
Step 3 We contact you about next steps.
Online submission Available

Important safety information

  • If you need urgent medical help, use NHS 111, 999 or local emergency care as appropriate.
  • Do not send medical information by replying to notification emails.
  • Questionnaire answers must be reviewed by an authorised clinician or prescriber before any prescribing decision.

After you submit

We may contact you if we need more information before a clinician or prescriber can make a decision.

Completing this questionnaire does not guarantee that treatment will be suitable or prescribed.

Before you start

This usually takes 8 to 10 minutes. Have ready: medicine list, allergies, weight, height, blood pressure if known, and GP surgery details.

Use this form for review

Your answers help Prosper Healthcare decide appropriate next steps. This is not an emergency service.

Secure and confidential

Submitted answers stay inside the signed-in CRM workspace. Do not reply to emails with medical information.

Check before sending

You will confirm declarations and your signature before final submission.

Progress checker

  1. 1. Consent and privacy
  2. 2. About you
  3. 3. Weight and lifestyle
  4. 4. Medical safety
  5. 5. Review and submit

Step 1 - Consent and privacy

Please read this short acknowledgement before entering personal or health information.

Important: This questionnaire is not a consultation. Completing it does not guarantee that treatment will be suitable or prescribed. A clinician or prescriber review is still required before any prescribing decision.

If you need urgent medical help, use NHS 111, 999 or local emergency care as appropriate.

Please read the terms and privacy notice before completing this questionnaire.

Terms and conditionsPrivacy notice
Consent and privacy agreement

Restart consultation

Ask to restart treatment after a break. Tell us about your previous treatment and when you stopped.

Choose a different consultation

Include the medicine name. If you do not know, write “Not sure”.

Copy the dose and units from your label if available, or write “Not sure”.

Enter the date, or select “I am not sure of the date” below.

Step 2 - About you

Tell us who the questionnaire is for and how we can contact you about the clinical review.

You must be 18 or over to use this service.

We use this to confirm we received your questionnaire and to contact you about next steps.

Use an 11 digit UK number, for example 07123456789. We use this if the clinical team needs to clarify an answer.

Leave this blank if you do not know it.

Choose the closest match. Select "Other / not listed" if your area is not shown.

Search by practice name, town or postcode, or type the surgery manually. If you are not registered with a GP, write "not registered".

Manual entry is available if your practice is not shown.

This helps the clinician interpret BMI and health risk. You can choose "Prefer not to say".

Step 3 - Weight and lifestyle

These answers help the clinician assess suitability and understand what support may be useful.

Choose the unit first, then enter your weight.

Choose the unit first, then enter your height.

Optional. Choose a unit if you know your waist measurement.

Example: 98 cm or 38.5 inches.

Leave blank if you do not know it. Example: 72 beats per minute.

Top number.

Bottom number.

Leave blank if you do not know it. If either number is high, we show same-day GP/NHS 111 advice.

Have you been diagnosed with any of these weight-related health conditions?
What is your reason for losing weight?
How are you feeling about making changes?
How much do you exercise per week?
How would you describe your diet?
Do you have any stressors?
What makes lifestyle changes harder for you?

Step 4 - Medical safety

Some questions are sensitive because they help the clinician assess safety and suitability. Your answers are reviewed confidentially by the clinical team.

If you need urgent medical help, do not wait for this questionnaire. Use NHS 111, 999 or local emergency care as appropriate.

Do you have any allergies or sensitivities?

Include tablets, injections or over-the-counter products if you remember them. Write "none" if you have not tried any before.

Are you currently using any of these weight-loss medicines or injections?

This helps the clinician avoid duplicate treatment or unsafe combinations. Select any that apply.

Are you taking any of the following medications?

Some medicines need extra monitoring or advice before weight-management treatment is considered.

Do you currently use an oral contraceptive pill?

This helps the clinician decide whether extra contraception advice is needed if Mounjaro is considered.

Do you use any medicine that can cause low blood sugar?

Low blood sugar can make you feel shaky, sweaty, confused, faint or unusually weak.

Have you recently had severe or repeated low blood sugar episodes?

Choose "Yes" if you needed help from someone else, nearly fainted, or this has happened more than once recently.

Type the medicine names if you know them. This is a free-text field; it does not expose an internal prescribing database.

Are you pregnant or breast-feeding or planning to conceive?

These answers are important because some weight-management medicines are not used during pregnancy, breast-feeding or while trying to conceive.

Are you aware of any liver or kidney problems?

Choose "I am unsure" if you have abnormal liver or kidney blood tests, specialist monitoring, or you are not sure what the diagnosis was.

Have you ever been told you had pancreatitis?

Pancreatitis means inflammation of the pancreas, which can cause severe stomach pain and may need hospital treatment.

Do you have any of these symptoms today?

If you have severe stomach pain or feel seriously unwell, do not wait for this form to be reviewed. Use urgent care, NHS 111, 999 or A&E as appropriate.

Have you had gallstones or gallbladder disease?

Gallbladder problems can cause pain under the right ribs or upper stomach, especially after food.

Do you have any gallbladder or jaundice symptoms today?

Jaundice means yellowing of the skin or eyes. Pale stools or dark urine can also be important warning signs.

Do any of these serious stomach or bowel problems apply to you?

These problems can affect whether some weight-management medicines are safe or need extra review.

Do you have a planned operation, endoscopy, anaesthetic or deep sedation soon?

Some weight-management injections slow stomach emptying, so the clinician needs to know about planned procedures.

Have you been diagnosed with heart failure?

This means a clinician has told you your heart is not pumping as well as it should.

Have you had weight-loss surgery such as gastric bypass, sleeve or band?

This is sometimes called bariatric surgery. It can affect medicine choice, nutrition and follow-up needs.

Have you had kidney stones or been told about oxalate kidney problems?

This is relevant because some treatments and diet changes can affect kidney-stone risk.

Do close relatives have heart-related problems?

For example, heart attack, stroke, heart failure, rhythm problems or heart disease in a parent, brother, sister or child.

Have you ever had an eating disorder or eating problems?

This can include binge eating, purging, severely restricting food, or being treated for an eating disorder.

Do you have any mental health history we should know about?

This helps the clinician understand support and safety needs. If you feel at immediate risk, use urgent mental-health support or emergency care.

Have you or a close blood relative had medullary thyroid cancer or MEN2?

This asks about a specific thyroid cancer risk. It is not asking about all thyroid conditions.

Do you have anything that needs urgent attention today?

This questionnaire is not an emergency service. Use 999, A&E or NHS 111 if you need urgent help.

Do you have any of the following conditions?

Choose any conditions a clinician has diagnosed. Select "None of the above" if none apply.

Have you ever been told you have diabetic eye disease, retinopathy, macular oedema or needed eye treatment for diabetes?

This only applies if you have diabetes or have been monitored for diabetes-related eye changes.

Have you had sudden or partial vision loss today or recently that has not been assessed?

If you have sudden vision loss, do not wait for this form to be reviewed. Seek urgent medical or eye-care advice.

Supporting medical records or results

Optional. Upload a recent result or record only if it will help the clinical review, for example HbA1c, TSH or T4 results.

Accepted formats: PDF, JPG, JPEG or PNG. Maximum 2 files, 5MB each. Files are stored securely for reviewer access only and are not sent by email.

Step 5 - Review and submit

Please check your answers before submitting. These declarations confirm how the questionnaire will be used and that clinician or prescriber review is still required before any suitability or prescribing decision.

Final declarations

Type your full name to confirm the information is accurate to the best of your knowledge.

Security check

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  • Online submission is available for this questionnaire.
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These checks help protect the form from spam and abuse.

Before you submit: a clinician or prescriber must review your answers before any treatment decision.