Medical Assessment

First Name

Last Name

Contact number

ID Number

Age

What is your goal weight?

What clothing size do you want to wear comfortably?

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

If you would still like to book an appointment to discuss your options, please send a request to support@meridianhealth.co.za.

Did you know?

Doctor-guided medical weight loss treatments have helped thousands of people feel more in control of their eating habits and reach their goals after years of unsuccessful attempts with other methods.

Current Weight (kg)

Height (cm)

BMI Result

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

If you would still like to book an appointment to discuss your options, please send a request to support@meridianhealth.co.za.

Did you know?

Many people say they finally feel in control of their weight for the first time with expert support and a personalised plan.

Please list all chronic medical conditions you have, and all surgeries you have had in the past:

Please list all medications, including contraceptives, that you are on:

Are you scheduled to have any surgeries? If yes, please list.

Please list any allergies that you have:

Did you know?

Unlike restrictive diets, expert-guided programmes are designed to support long-term, sustainable weight management.

Do you have any of the following conditions?

Type 1 diabetes?

Yes

Personal or family history of medullary thyroid carcinoma (MTC)?

Yes

Multiple endocrine neoplasia syndrome type 2 (MEN2)?

Yes

Pregnant, breastfeeding, or planning to become pregnant in the near future?

Yes

Current or prior history of bulimia or anorexia?

Yes

Current or prior history of suicide attempts or suicidal ideation?

Yes

Allergy/hypersensitivity to any GLP-1 agonists?

Yes

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

If you would still like to book an appointment to discuss your options, please send a request to support@meridianhealth.co.za.

Did you know?

Many people following expert-guided weight programmes say they have more energy, sleep better, and feel more confident.

Did you know?

Studies show that modern medical weight loss medications can help people lose on average 23% of their starting body weight.

Which city do you live in?

Would you like us to call you to answer any questions you may have about medical weight loss with Meridian Health?

Yes please

No thank you

And lastly, how did you hear about us?

Unfortunately, our screening questionnaire has identified one or more factors which make GLP-1 medications inappropriate or unsafe for you.

If you would still like to book an appointment to discuss your options, please send a request to support@meridianhealth.co.za.

I agree to the Meridian Health Terms and Conditions and consent to my personal medical information being used by Meridian Health as outlined in the Privacy Policy

Our screening questionnaire indicates that GLP-1 agonist medications are likely safe and appropriate for you. Please book an appointment with one of the doctors.

Click "submit" to proceed with booking an appointment.

Online Evaluation

Complete Online Assessment

Virtual Appointment

Personalised Plan

Virtual Follow-Ups

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Do you have any of the following conditions?

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