Please completed the form for the Strathearn Health & Beauty Weight Management Programme.                                                                    * are mandatory fields.

Please select any of the following which apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Title                                    Forename                                                                    Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

IN CASE OF EMERGENCY

Please provide contact details for us to contact someone in the event of emergencies.

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

GP Details

{ binding firstError.message }
Address of your GP Surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

DECLARATION

Strathearn Health & Beauty advises all patients to share details of their Treatment at our clinic with the patient's own GP and/or healthcare providers. ALL patients will be given a GPL1 (Letter to GP) which will be located in the Patient Portal.  This can be emailed, printed or posted to the Patient's GP by the patient at any time. 

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

YOUR MEDICAL HISTORY

Please tick if you suffer from or have ever suffered from any of the following conditions.

 

Please tick if you suffer from or have suffered from any of the following conditions: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Are you taking any or have taken any of the following or any other medication/herbal supplements (i.e St John's Wort)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Do you smoke? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Do you drink alcohol? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

One unit is the equivalent of:   1/2 pint of normal strength beer, lager or cider.1 small glass of wine. One single (25ml) measure of spirits or 1 small glass (50ml) of Sherry or Port. 

Have you ever used any of the following medications/Herbal to lose weight? If YES, please indicate how successful they were.

Diethylpropion/Tenuate Dospan {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Phentermine/Ionamin/Duromine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Xenical/Orlistat {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Bulking Agents {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Herbal Preparations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

ABOUT YOUR WEIGHT, EATING, EXERCISE AND APPETITE SUPPRESSANTS.

{ binding firstError.message }
{ binding firstError.message }
Weight measured in Stones and lbs or Kilos {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Please indicate your reasons for wanting to lose weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Which of these factors have caused you to put on weight: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Please complete the following questions regarding your eating and exercise patterns: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
ALWAYSUSUALLYSELDOMNEVER
{{ $context.parentContext.dataItem.get_label() }}
{ binding firstError.message }
{{ $context.parentContext.dataItem.get_label() }}
{ binding firstError.message }
{{ $context.parentContext.dataItem.get_label() }}
{ binding firstError.message }
{{ $context.parentContext.dataItem.get_label() }}
{ binding firstError.message }
{{ $context.parentContext.dataItem.get_label() }}
{ binding firstError.message }
{{ $context.parentContext.dataItem.get_label() }}
{ binding firstError.message }
{{ $context.parentContext.dataItem.get_label() }}
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Have You Consulted With Your GP About Your Weight? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Have You Consulted With Your GP About Taking Appetite Suppressants? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you researched Appetite Suppressant Medication (UK Specials)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you been on any of the following Weight Loss Programmes? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

If "YES" please indicate how successful they were:

{ binding firstError.message }
{ binding firstError.message }
In order to lose weight, I must follow a calorie controlled plan and understand that any appetite suppressants prescibed to me by the clinic doctor is only to help curb appetite and is not for obesity.
I agree to the above statement: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Please click on the link to read the statement before agreeing to proceed with your Weight Management Clinic Application.

PATIENT CONSENT FOR WEIGHT MANAGEMENT TREATMENT

Consent to Proceed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

CONFIDENTIALITY

All patient information including pictures held by Strathearn Health & Beauty Ltd is private and confidential and compliant with GDPR regulations.  On occasion, regulatory bodies may inspect your file.  Further information on access to medical and treatment records is available on the department of health website: www.nhs.uk.

COMPLAINTS

If you wish to make a complaint, you can do so by calling the clinic on 0141 333 1900, sending an email to info@strathearnhealthandbeauty.co.uk and as from 1st April 2017, you can also contact Healthcare Improvement Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB, or by calling 0131 623 430.  Please see our website for full details of our complaints procedure at: Strathearn Complaints Procedures.  We are a member of ICO.

Please completed the form for the Strathearn Health & Beauty Weight Management Programme.                                                                    * are mandatory fields.

Please select any of the following which apply to you {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Title                                    Forename                                                                    Surname {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date Of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Sex/Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Mobile Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Occupation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

IN CASE OF EMERGENCY

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Relationship to Patient {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Contact Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

GP Details

Your GP Name or Surgery Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address of your GP Surgery {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Telephone No {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

DECLARATION

I understand the importance of sharing my treatment information wth my own GP {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I DO NOT wish to share this information with my GP nor do I give consent for my GP to be contacted by the clinic. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Patient's Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

YOUR MEDICAL HISTORY

Please tick if you suffer from or have suffered from any of the following conditions: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Any Other Health Conditions Not Mentioned above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are you taking any or have taken any of the following or any other medication/herbal supplements (i.e St John's Wort)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If YES, please give a description of the medication/supplement and what you use it for. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
when did you last take a dose? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you smoke? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
How Many Per Day {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you drink alcohol? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Units Per Week {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

One unit is the equivalent of:   1/2 pint of normal strength beer, lager or cider.1 small glass of wine. One single (25ml) measure of spirits or 1 small glass (50ml) of Sherry or Port. 

Have you ever used any of the following medications/Herbal to lose weight? If YES, please indicate how successful they were.

Diethylpropion/Tenuate Dospan {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Time on Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phentermine/Ionamin/Duromine {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Time on Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Xenical/Orlistat {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Time on Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Bulking Agents {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Time on Bulking Agent {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Herbal Preparations {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Time on Herbal {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Others? Please specify {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Time on Others {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }

ABOUT YOUR WEIGHT, EATING, EXERCISE AND APPETITE SUPPRESSANTS.

What is your Height (Feet and Inches) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
What is your current Weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight measured in Stones and lbs or Kilos {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Please indicate your reasons for wanting to lose weight {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
If "Other" Please Specify Untitled {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Which of these factors have caused you to put on weight: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Please complete the following questions regarding your eating and exercise patterns: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{{ $dataItem.get_label() }}
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
How much weight to you want to lose? (14lbs in 1 Stone) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How long do you think it will take to achieve the weight loss? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have You Consulted With Your GP About Your Weight? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
IF "YES" What Was The Outcome? If NO Please State Why: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have You Consulted With Your GP About Taking Appetite Suppressants? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you researched Appetite Suppressant Medication (UK Specials)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you been on any of the following Weight Loss Programmes? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

If "YES" please indicate how successful they were:

Time on Programme {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Weight Lost {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
In order to lose weight, I must follow a calorie controlled plan and understand that any appetite suppressants prescibed to me by the clinic doctor is only to help curb appetite and is not for obesity.
I agree to the above statement: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Please click on the link to read the statement before agreeing to proceed with your Weight Management Clinic Application.

PATIENT CONSENT FOR WEIGHT MANAGEMENT TREATMENT

Consent to Proceed {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

CONFIDENTIALITY

All patient information including pictures held by Strathearn Health & Beauty Ltd is private and confidential and compliant with GDPR regulations.  On occasion, regulatory bodies may inspect your file.  Further information on access to medical and treatment records is available on the department of health website: www.nhs.uk.

COMPLAINTS

If you wish to make a complaint, you can do so by calling the clinic on 0141 333 1900, sending an email to info@strathearnhealthandbeauty.co.uk and as from 1st April 2017, you can also contact Healthcare Improvement Scotland, Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB, or by calling 0131 623 430.  Please see our website for full details of our complaints procedure at: Strathearn Complaints Procedures.  We are a member of ICO.