DAM Components

1. About You

In Progress

Your Details

First Name

Last Name

Email Address

Phone Number

Question 1What is your age?

19 - 74

75 - 84

Question 2What was your sex registered at birth?

Male

Female

Question 3What is your height?

Switch to cm

Question 4What is your current weight?

(Please provide an accurate,up-to-date measurement. Evidence may be required.) *

lbs

Switch to kg

Question 5What is your ethnicity?

Please select an option

Question 6Do you have any of the following conditions?

Severe Hear Failure

Kidney Impairment

Diabetic Retinopathy

Pancreatitis

Gastroparesis

Ulcerative Colitis or Crohn’s Disease

History or family history of Thyroid Cancer, Medullary Thyroid Cancer or MEN2

Any Cancer, current chemotherapy or radiotherapy

None of the above

Question 7Do you have gallbladder or bile duct issues?

Yes

Question 8Do you have diabetes?

Please inform us if your doctor prescribes any medication for your pre-diabetes or diet-controlled diabetes, as it may affect your treatment. Proceed to Q10.

I have pre-diabetes

Yes and I take medication for my diabetes

Question 9Do you have liver impairment?

Yes

Question 10People with weight-related medical conditions may be prescribed weight loss medicines at a lower
BMI than other patients, if suitable. Please let us know if you have any of the following
weight-related conditions:

On treatment for Depression linked to your weight

People with weight-related medical conditions may be prescribed weight loss medicines at a lower BMI than other patients, if suitable. Please let us know if you have any of the following weight-related conditions: *

High Blood Pressure

Erectile Dysfunction

Cardiovascular Disease (Such as heart attack, Atrial Fibrillation

Knee or Hip osteoarthritis

Asthma

COPD

Obstructive Sleep Apnoea

High Cholesterol

Polycystic Ovary Syndrome (PCOS)

Peri-menopause / Menopause

Other

None of the above

Question 11Have you ever made yourself sick (vomit) to control your shape or to lose weight?

Yes

Question 12In the last year, have you taken laxative medication in order to lose weight? *

Yes

Question 13Do you worry that you have lost control over how much you eat? (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time?)

Yes

Question 14Would you say that food or image dominates your life?

Yes - Food and Image

Yes - Food

Yes - Image

No, neither

Question 15Do you ever eat in secret?

Yes

2. Medical History

Incomplete

3. Your Treatment

Did you receive your last supply from ourselves, DAM Health?

Yes

No I received it from another pharmacy / clinic

How long have you been using Wegovy?What was your weight when you started Wegovy?

Would you like to continue with Wegovy? *

Yes, I’m happy with Wegovy

No, I would like to switch to Mounjaro

If you are on 0.25mg or 0.5mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Mounjaro. If you are on 1mg, 1.7mg or 2.4mg you must stop treatment for at least 4 weeks prior to starting Mounjaro.

Check to agree

What dose did you last use?

Would you like to remain at your current dose, increase or reduce to the next dose?

I’m happy with my current dose

I would like to reduce to the previous lower dose

Would you like to remain at your current dose, increase or reduce to the next dose?

Achieving weight aims

Cost

Side Effects

Other

Please provide more information below

Is there any other information you feel would be useful for our clinicians to know about?

Yes

Please provide more information below

Details of your current GP. To ensure the best level of care, you must provide these details before you can proceed. We will notify your GP if a supply is made. Your order may be delayed if you do not enter the correct GP name and address. *

To assess your weight, BMI, and medical history, we need a clear photo of your full body. This helps our clinical team determine your suitability for weight care treatment.

PositionStand facing the camera for a full-body photo (head to feet preferred). If not possible, a head-to-hip photo is okay. Please avoid selfies that only show your face.

PoseStand relaxed, facing forward with arms at your sides and feet shoulder-width apart.

BackgroundUse a clear, well-lit background with no glare or obstructions.

ClothingWear one layer of form-fitting clothing so your body shape is visible.

Take your timeUse the 10-second timer to get into position. You can retake the photo if needed.

Can’t take a photo right now?Select ‘Take photo later’ to upload it later. Please note, we cannot approve your order until your photo is submitted.

To process your order, we need a photo to help our clinicians assess your suitability for treatment. After placing your order, you’ll receive an email with instructions on how to take and upload your photo at a time that’s convenient for you.

4. Acknowledgments

Incomplete

3. Treatment

Incomplete