Slim Pen
Medical Health Questionnaire
Private and Confidential
Preferred method of contact:
1. On completing this medical questionnaire, I am hereby agreeing to the Slim Pen terms and conditions and understand that I agree to follow the guidelines given to me by my practitioner.
2. I consent to my details being recorded and kept on file
3. I understand that drinking alcohol is not advisable and can affect the results
4. I understand and agree to store slim pen in a refrigerator ideal temperature is between 2-8 degrees
5. I understand that weight loss although clinically proven is not guaranteed by Slim Pen
6. I also agree that if I do not follow the guidelines correctly my weight loss goals may not be achieved
7. I understand that once the Slim Pen has been issued to me, that under no circumstances will Slim Pen issue a refund
8. I understand that the slim Pen and needles must be stored safely out of the reach of children
9. If I were to get any side effects I will inform Slim Pen
10. I understand that if I cannot for any reason continue with my issued Slim Pen due to side effects or changed my mind, a refund will not be issued
11. I understand that if after my consultation with the practitioner, if I am not suitable for the Slim Pen I will be given a full refund
12. I understand that the slim pen will not be issued to me without a face to face consultation with the Slim Pen practitioners
13. I understand that if I want Slim Pen to write and inform my GP or write a letter for travel, there will be a £25 charge
14. I understand that due to the nature of the Slim Pen being s clinically proven medication, I can only be issued 1 pen at a time, with a minimum of 2 weeks between purchases:
15. I agree that the slim Pen issued to me, is solely for my use, and only to be used as directed by my practitioner
16. I understand that if I fail to attend my appointment with the practitioner without 24 hours cancellation, I will lose my deposit
17. I understand that in line with the GDPR May 2018 my information will only be kept for use by Slim Pen
Emergency Contact Details
What would you like to achieve from Slim Pen?
18. Do you have any allergies?
19. What medication if any are your currently taking:
20. Do you have any medullary thyroid cancer or thyroid cancer in your family?
21. Do you have diabetes?
22. Do you have any stomach disorders? E.g. Ulcers etc.
23. Have you ever had pancreatitis?
24. Have you ever been diagnosed with colitis or crohns disease?
25. Are you pregnant or breastfeeding?
26. Please list any contraception that you are currently taking:
27. What is the date of your last period?
28. Have you ever had any gynaecological problems?
29. What is general health?
31. How many units of alcohol do you drink a week?
For information on number of units visit NSH website​
32. Are you Vegetarian/Vegan?
33. Do you have any food intolerance that you know of?
35. Have you ever been treated for an eating disorder?
36. Have you had any surgery?
37. Do you suffer from heart palpitations?
38. Have you ever had any heart conditions?
39. Have you ever had an abnormal ECG?
40. Have you ever had any type of cancer or undergoing any cancer treatment?
41. Are you being treated for any chronic illness? i.e. Asthma