Weight management assessment

The NHS has begun an exercise to have patients recruited into a national weight management programme.

Please fill out your information below and indicate if you would like to be referred into this programme.

Full Name

Address 

Postcode 

Date of Birth 

Home phone number 

Home phone number

Email address

1. Are you diabetic? yesno

2. Do you suffer from heart disease? yesno

3. Do you smoke? yesno

4. What is your height? 

5. What is your weight? 

6. Do you suffer with high blood pressure? yesno

7. Do you know your most recent blood pressure reading? Enter number in box if known

8. When was your latest blood test?

9. Do you consent to the referral to weight management programme? yesno

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