Health Assessment - You & I Aesthetics

Part 1: Personal Information

First Name + Last Name

Gender (assigned at birth)

Part 1: Personal Information

Ethnicity

Date of Birth

Part 1: Contact Information

Address

Phone Number

Part 1: Contact Information

Email Address

Occupation

Part 2: Goals and Motivations

What motivates you to lose weight?

Part 2: Goals and Motivations

What is your current weight? (kg)

What is your current height? (cm)

Part 2: Goals and Motivations

What is your target weight? (kg)

Do you have scales at home?

Yes No

We strongly encourage you to monitor your weight on a weekly basis to track your progress.

Part 3: Weight History

Did you experience any challenges related to your weight when you were a child?

Yes No

Tell us more:

Part 3: Weight History

What was your weight when you left school?

Is there a family history of obesity or excess weight?

Yes No

Tell us more:

Part 3: Weight History

How long have you been overweight?

What was your weight one year ago?

Part 3: Weight History

What has been your heaviest weight? When was this? Please tell us more.

Part 3: Weight History

What has been your lowest weight? When was this? Please tell us more.

Part 3: Weight History

How many times have you lost at least 5-10kg in your life?

Part 3: Previous Diet Attempts

Part 3: Previous Medication Attempts

Which of these medications have you trialled before? (Select all that apply)

Phentermine (Duromine) Contrave Metformin Orlistat Liraglutide (Saxenda) Dulaglutide (Trulicity) Semaglutide (Ozempic, Wegovy) Tirzepatide (Mounjaro, Zepbound) Other

Part 3: Bariatric Surgery History

Have you had bariatric surgery before?

Yes No

If so, which operation?

Part 3: Weight History

Please feel free to elaborate on your weight loss journey. Please include details such as history of yo-yo dieting, timeline of your weight, amount of weight gain/loss with life events etc.

Part 4: Diet History

Could you please describe everything you ate and drank yesterday, from the time you woke up until you went to bed? Breakfast:

Morning Tea:

Lunch:

Afternoon Tea:

Dinner:

Snacks:

Drinks:

Water (estimated volume):

Part 4: Diet History

What are some of your typical snacks, and how often do you generally snack throughout the day?

Part 4: Diet History

Do you go back for seconds?

Yes No

Do you struggle to feel full or satisfied after a meal?

Yes No

Part 4: Diet History

How often would you have takeaways?

Part 4: Diet History

Do you have a sweet tooth?

Yes No

Do you have grazing behaviour?

Yes No

Part 4: Eating Habits

Are you an emotional eater?

Yes No

Please describe:

Part 4: Eating Habits

In the past three months, have you had times when you ate a much larger amount of food than most people would in a similar time (say, within 2 hours), and felt like you couldn't stop eating or lost control during that time?

Yes No

Can you give me an example of what you ate during one of these times, and roughly how much?

Were you embarrassed or felt guilty about the amount you ate?

Did you ever make yourself vomit?

Yes No

Part 4: Eating Triggers

What situations or feelings tend to make you want to eat, even when you're not physically hungry?

Part 4: Eating Triggers

Do you have a desire to eat 1. When things go wrong? 2. When you are lonely? 3. When you feel down?

Part 4: Eating Triggers

When you feel emotionally upset or when someone lets you down, do you have a strong desire to reward yourself with food?

Part 4: Dietary Requirements

Do you have any food allergies, intolerances, or religious dietary requirements?

Do you regularly consume alcohol?

Yes No

Please detail the amount and frequency of alcohol intake:

Part 5: Exercise History

How many times do you exercise per week?

Could you please detail the type of exercise you're currently doing?

Part 6: Medical History

Please list all medical conditions that you may have:

Part 6: Medical History

Please list all prescription medications you are currently taking:

Part 6: Medical History

Do you have any medication allergies?

Yes No

Please detail:

Part 6: Medical History

Do you currently smoke/vape?

Yes No

Do you have a history of pre-diabetes or diabetes?

Yes No

Please specify:

Part 6: Medical History

Do you have high blood pressure?

Yes No

Do you know if you have high cholesterol?

Yes No

Part 6: Medical History

Have you had a heart attack or stroke?

Yes No

Please detail:

Do you have any kidney disease?

Yes No

Please detail:

Part 6: Personal Health

Are you prone to constipation?

Yes No

Please detail:

Part 6: Personal Health

Are you currently pregnant?

Yes No

Are you currently breast-feeding?

Yes No

Part 6: Personal Health

Are you currently using contraception?

Yes No

Please detail:

Part 6: Personal Health

Do you have your periods regularly?

Yes No Post-menopausal Male

Please describe your typical cycle:

Part 6: Mental Health & Sleep

Have you been diagnosed with an eating disorder before?

Yes No

Please detail:

Part 6: Mental Health & Sleep

Have you been treated for depression/anxiety?

Please feel free to elaborate:

Part 6: Mental Health & Sleep

Do you take any medications for sleep?

Yes No

Please detail:

Part 6: Mental Health & Sleep

Do you snore loudly?

Yes No

Have you been seen stopping breathing while you sleep?

Yes No

Part 6: Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently, try to work out how they would have affected you.

Situation	No chance (0)	Slight chance (1)	Moderate chance (2)	High chance (3)
Sitting and reading
Watching Television
Sitting inactive, in a public space
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
As a passenger in a car for an hour without a break
In a car, while stopped for a few minutes in traffic

Your Total Score: 0 / 24

Part 6: Medical History Checklist

Do you have any reflux?

Yes No

Do you have any painful joints in the lower back, hip or knees?

Yes No

Please provide details:

Part 6: Medical History Checklist

Any current/past gallstone problems?

Yes No

Please provide details:

Part 6: Medical History Checklist

Have you had any chest pain, shortness of breath on exertion, or palpitations?

Yes No

Please provide details:

Part 6: Medical History Checklist

Any history of seizures?

Yes No

Please detail:

Any history of pancreatitis?

Yes No

Please detail:

Part 6: Medical History Checklist

Any history of Glaucoma?

Yes No

Please detail:

Family or personal history of thyroid cancer?

Yes No

Please detail:

Part 6: Medical History Checklist

Any history of abdominal surgery?

Yes No

Please provide details:

Part 7: GP Information

Please share your GP's name and the medical centre you are enrolled in.

Do you agree for us to send your notes to your GP?

Yes, I agree

Part 8: Conclusion

Thank you for your time to complete this assessment. We rely on your honest answers to create the best treatment plan for you.

Please tick the following boxes if you agree:

I acknowledge that I have honestly answered the questions to the best of my knowledge I agree to the terms and conditions I agree to subscribe to You & I Aesthetics's mailing list for updates

Important Disclaimer

Part 1: Personal Information

Part 1: Personal Information

Part 1: Contact Information

Part 1: Contact Information

Part 2: Goals and Motivations

Part 2: Goals and Motivations

Part 2: Goals and Motivations

Part 3: Weight History

Part 3: Weight History

Part 3: Weight History

Part 3: Weight History

Part 3: Weight History

Part 3: Weight History

Part 3: Previous Diet Attempts

Part 3: Previous Medication Attempts

Part 3: Bariatric Surgery History

Part 3: Weight History

Part 4: Diet History

Part 4: Diet History

Part 4: Diet History

Part 4: Diet History

Part 4: Diet History

Part 4: Eating Habits

Part 4: Eating Habits

Part 4: Eating Triggers

Part 4: Eating Triggers

Part 4: Eating Triggers

Part 4: Dietary Requirements

Part 5: Exercise History

Part 6: Medical History

Part 6: Medical History

Part 6: Medical History

Part 6: Medical History

Part 6: Medical History

Part 6: Medical History

Part 6: Personal Health

Part 6: Personal Health

Part 6: Personal Health

Part 6: Personal Health

Part 6: Mental Health & Sleep

Part 6: Mental Health & Sleep

Part 6: Mental Health & Sleep

Part 6: Mental Health & Sleep

Part 6: Epworth Sleepiness Scale

Part 6: Medical History Checklist

Part 6: Medical History Checklist

Part 6: Medical History Checklist

Part 6: Medical History Checklist

Part 6: Medical History Checklist

Part 6: Medical History Checklist

Part 7: GP Information

Part 8: Conclusion

Your Assessment Results