Demo Clinic logo

Welcome to

Demo Clinic

Complete your online consultation with Demo Clinic to begin your weight loss journey

Share This Form

Know someone who might benefit? Share this consultation form with them

Email WhatsApp Facebook

Consultation Progress

0% complete
1

About You

Tell Demo Clinic about yourself to get started

Gender *

Enter kg (auto-fills st/lbs)

2

About Your Health

Help us understand your medical history

2.1 Do you suffer from any heart problems? *
2.2 Do you have any thyroid problems? *
2.3 Thyroid cancer in you or immediate family? *
2.4 Pancreatitis (current or past)? *
2.5 Kidney problems? *
2.6 Liver problems? *
2.7 Severe gastro-intestinal problems? *
2.8 Diabetes? *
2.9 Mental health problems? *
2.10 Eating disorder? *
2.11 Other medical problems? *
2.12 Other medication not already identified? *
2.13 Known allergies? *
2.14 Permission to inform your GP? *
3

About Your Lifestyle

Tell us about your daily habits and routines

3.1 Do you smoke? *
3.2 Do you drink alcohol? *

Excessive alcohol can increase health risks. For support cutting down, visit this page.

Staying hydrated helps reduce constipation.

Poor sleep affects hunger hormones.

NB: 150 min moderate or 75 min vigorous recommended.

4

Your Weight-Loss Journey

Tell us about your weight loss experiences and goals

4.3 What contributes to your excess weight? *
4.5 Currently taking any treatments (Mysimba, Saxenda, Ozempic, Phentermine)? *
5

Declaration & Consent to Treatment

Please review and agree to the terms and conditions

5.1 Tick to confirm each statement:
5.2 How did you locate this form? *
6

Readiness to Change

Help us understand your motivation and readiness

6.1 Motivated to lose weight? *
6.2 Motivated to change eating habits? *
6.3 Motivated to increase physical activity? *
6.4 Motivated to try new strategies/techniques? *
6.5 Confidence to devote time & effort now – next few months? *
6.6 Confidence to record intake & activity for 2–4 weeks? *
6.7 Satisfaction if 10% weight loss improves health & quality of life? *

By submitting, you agree the information provided is accurate to the best of your knowledge. Your consultation will be reviewed by Demo Clinic.