Patient Intake Form — Metabolic Doc

Step 1 of 6

Let's start with the basics.

This information is kept strictly confidential and is never shared without your written consent.

Name and surname *

Please enter your name and surname

Email address * Your booking confirmation and consultation link will be sent here

Please enter a valid email address

Contact number *

Please enter your contact number

Date of birth *

Please enter your date of birth

Sex assigned at birth *

Please select an option

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Step 2 of 6

Your health & measurements.

Be as accurate as possible — this helps your doctor assess whether GLP-1 therapy is suitable for you.

Current weight * In kilograms (kg)

Please enter your current weight

Height * In centimetres (cm)

Please enter your height

⚠️

GLP-1 therapy may not be indicated

Based on your height and weight, your BMI is below the clinical threshold for GLP-1 weight management therapy (BMI ≥30, or ≥27 with a weight-related health condition). Your doctor will still review your full form, but please be aware that a prescription may not be appropriate. You're welcome to continue — your R700 consultation and script fee will not be charged until after the call if you choose not to proceed.

Do you have any of the following conditions? * Select all that apply

Type 2 Diabetes (T2DM)Including if you're currently on diabetes medication High blood pressure (Hypertension) High cholesterol / Dyslipidaemia Polycystic Ovary Syndrome (PCOS) Fatty liver disease (NAFLD/MASLD) Sleep apnoea Heart disease / Cardiovascular diseaseIncluding history of heart attack or stroke Kidney disease (CKD)If known — please specify stage if you know it None of the above

Please select at least one option

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Step 3 of 6

Current medications.

Include everything — prescription medicines, supplements, vitamins, and over-the-counter products. Some medications interact with GLP-1 therapy.

List your current medications Name, dose, and what it's for if you know it — e.g. "Metformin 500mg twice daily for diabetes"

Please list your current medications

Any known drug allergies?

Step 3 of 6

Step 4 of 6 — Important

Safety questions.

These questions identify conditions that may make GLP-1 therapy unsafe. Please answer honestly — your safety is the priority.

Do you have a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN2)? *

Yes — I or a direct family member has been diagnosed with MTC or MEN2 No I'm not sure / I don't know my family history

Please answer this question

⛔

We're unable to proceed with GLP-1 therapy

A personal or family history of medullary thyroid carcinoma (MTC) or MEN2 syndrome is an absolute contraindication to GLP-1 therapy. This is not reversible and we cannot prescribe these medications for you. We recommend discussing alternative weight management options with your GP or an endocrinologist.

Have you ever been diagnosed with pancreatitis (inflammation of the pancreas)? *

Yes — currently active or recent episode Yes — but resolved, more than 12 months ago No

Please answer this question

⛔

We're unable to proceed at this time

Active or recent pancreatitis is a contraindication to GLP-1 therapy. Please speak to your GP or gastroenterologist before pursuing any GLP-1 treatment. Once fully resolved for 12+ months, you may be reassessed.

Are you currently pregnant, planning to become pregnant within the next 12 months, or breastfeeding? *

Yes No

Please answer this question

⛔

GLP-1 therapy is not safe during pregnancy or breastfeeding

These medications are contraindicated during pregnancy, planning to conceive, and while breastfeeding. We recommend speaking to your GP or OB/GYN about weight management options appropriate for your situation.

Do you have a current or recent (past 2 years) history of an eating disorder? * Including anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID

Yes — current or within the last 2 years Yes — but more than 2 years ago and I'm in stable recovery No

Please answer this question

⛔

We'd like to refer you to specialist support first

Active or recent eating disorders require specialist psychological support before starting GLP-1 therapy. GLP-1 medications significantly reduce appetite, which may complicate eating disorder recovery. We recommend speaking to a psychologist or psychiatrist specialising in eating disorders before pursuing this treatment.

Have you had a gastrectomy (stomach removed or reduced) or bariatric surgery? *

Yes No

Please answer this question

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Step 5 of 6

Your goals & history.

Understanding your history helps your doctor personalise your treatment plan and set realistic expectations.

Target weight (kg) Your goal — not a commitment

What is your main motivation for starting this programme?

Improving my health / reducing health risksDiabetes, blood pressure, joint pain, etc. How I look and feel about myself Energy levels and quality of life A combination of all of the above

Anything else you'd like your doctor to know before the consultation?

Step 5 of 6

Step 6 of 6 — Final step

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Step 6 of 6

Let's start with the basics.

Your health & measurements.

GLP-1 therapy may not be indicated

Current medications.

Safety questions.

We're unable to proceed with GLP-1 therapy

We're unable to proceed at this time

GLP-1 therapy is not safe during pregnancy or breastfeeding

We'd like to refer you to specialist support first

Your goals & history.

Almost there.
Please read and agree.

You're all set.

What happens next

Let's start with the basics.

Your health & measurements.

GLP-1 therapy may not be indicated

Current medications.

Safety questions.

We're unable to proceed with GLP-1 therapy

We're unable to proceed at this time

GLP-1 therapy is not safe during pregnancy or breastfeeding

We'd like to refer you to specialist support first

Your goals & history.

Almost there.Please read and agree.

🔒 Terms of Care & Consent

✅ Accuracy declaration

📜 Terms & Conditions

You're all set.

What happens next

Almost there.
Please read and agree.