Metabolic syndrome, overweight, obesity - identification and risk reduction

What this assessment aims to do:
The information you provide here will help to assess whether your nutrition is balanced, if you are risk of metabolic syndrome, and if your weight is healthy in the context of your ethnicity and familial risk.
If your risk of developing weight related health problems is higher, you will be offered some options to help you lose weight and modify your lifestyle.
Understanding of your own risk will reduce anxiety and help you make informed choices including but not limited to safer treatment options.
Protecting your data
Form submissions will not be possible without express consent from you in the checkbox below, as per GDPR.
I am 18 or older*
I am 18 or older and I consent to having the clinic collect my details, store and use my information in the manner described above
- Agree
Terms and conditions
This assessment is not designed to diagnose or treat any condition on its own. Your responses will be used by the requesting doctor to assess your general state of health overall; your risk of developing health problems; and help them recommend services and safe options for you.
The online assessment is not intended to be a substitute for professional medical care. Never disregard professional medical advice or delay seeking medical care because of something you have read here.
If you are experiencing a life-threatening emergency, please call 999 immediately.
Data use
- * This information is requested for the specific purpose of carrying out your health risk assessment.
- * We will NEVER share your data for purposes other than this.
Your agreement to these terms*
By checking the box below, you indicate your agreement to these terms, conditions and use of the information you provide for your risk assessment.
- Agree

What information is being asked for:
In the following sections you will be asked about:
- * Your age, gender, lifestyle, and environmental factors linked to metabolic syndrome
- * Your health history such as diabetes, heart, circulation, and medications you take.
- * Symptoms you having (if any) and any tests you may have had.
The requesting doctor will evaluate your responses, and get back to you with next steps. Please note: if you have any urgent symptoms, please contact your local NHS helpline. This assessment is not for urgent care. It is intended to help in the planning of elective care and health risk mitigation for you.
Some questions have been included from the COVID-19 Vulnerability Index based on the increased vulnerability of those with overweight and obesity to complications of COVID-19. This combines CDC risk factors with other related risk factors for severity of respiratory infections, to help individuals understand how vulnerable they or their loved ones are to complications from COVID-19. Thus, it helps you make informed decisions and remain safe.
Please contact me by the method(s) selected below:*
At least one selection is required to enable us to respond to you. Email is ideal for conveying results to you.
- Email
- Phone
- SMS

About you
Name*
Title First Middle Last
Date of Birth*
Gender*
- Female
- Male
- Other
Are you pregnant, breastfeeding or trying to get pregnant?
- No
- Yes
Are you on any contraception?*
include the pill, depo injection, mirena, implanon, nexplanon or copper coil
- No
- Yes
Any comments on periods or if menopausal
Email
Phone*
Your preferred contact phone number
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Registered GP Surgery*
The name of the NHS GP surgery you are registered with. If you do not have a named GP, that is okay, I just need the name and contact details of your registered surgery under GMC guidelines.
Informing your GP*
When patients receive prescription treatment outside of the NHS, it is required to keep NHS GP informed of these. This is to help your GP avoid any interactions with other medications that you may be prescribed. Please select "YES" to give your permission for this. Please note that weight loss medication should not be prescribed without informing your GP.
- No
- Yes

Could you be at risk of metabolic syndrome?
What is metabolic syndrome?
Metabolic syndrome is a group of health problems that make it more likely you will have a heart attack or stroke or develop diabetes. If you have metabolic syndrome, you have atleast three of the following:
1 - Too much fat around your waist.
2 - Borderline or high blood pressure.
3 - Borderline or high blood sugar.
4 - Raised triglycerides, a type of fat in your blood.
5 - Low "good" HDL cholesterol.
You may have increased risk if:
1 - You are overweight or obese, especially ifyou carry a lot of weight around your waistand upper body.
2 - Your family members have or had type 2 diabetes and are or were overweight.
3 - You have other conditions which make it difficult for you to exercise, cut calories or control appetite. These could be physical or psychological trauma, stress both mental and physical.
So what can you do about it?
Lifestyle modification designed around you is the basis for any successful programme. If you are found to have high risk measure of abdominal circumference (girth) or weight, weight reduction is essential. For this, a calorie deficit is needed.
A personalised nutritional programme will help you to do this. Sometimes, prescription medication will help balance the hormones that signal your appetite and fullness, helping you to maintain the calorie control. If you have a hormonal imbalance such as an underactive thyroid, it will help to treat this, since the thyroid affects your energy, metabolism and appetite
Physical or psychological trauma and stress will predispose to "stress"-eating, and in such situations, it may help to assist your weight loss efforts with medication.
Do you feel you are at risk of metabolic syndrome or obesity?
In your own words, please share your motivation to reduce your health risk. You will be asked about specific medical history further along the questionnaire.

Ethnicity and BMI risk factors
Studies have shown that the following have a significant impact on your risk, although we do not mentally associate these with being ill.
Ethnicity*
Please choose which of the following you would describe yourself as:
- White British (Welsh, English, Scottish, Northern Irish, British, Irish)
- Mixed (Multiple ethnic groups)
- Middle Eastern, Asian or Southeast Asian (Indian, Pakistani) British
- Black British including Caribbean
Choose your preferred system of measurement*
For height in feet and inches, weight in stone and pound, select Imperial. For height in meters and centimeters, weight in kilograms, select Metric.
- Imperial
- Metric
Height
Feet
Inches
Meters
Centimeters
Weight
Stone
Pounds
Kilograms
This field is hidden when viewing the form
BMI calculation from imperial HIDDEN FIELD
This field is hidden when viewing the form
BMI calculation from metric HIDDEN FIELD
Your Body Mass Index BMI
How to interpret BMI (actual risk may vary by ethnicity and muscle mass)
Below 18.5: Underweight
18.5-25 : Healthy Weight Range
25-30 : Overweight
Over 30 : Obese
**If you are a bilateral lower limb amputee, height ranges do not apply and special calculations are needed. For all other amputations and limb discrepancies, please use this calculator and results, but specify in the final comments box the details of your amputation or limb discrepancy.
Your abdominal circumference in Inches
Measure at the level of 2 inches above your umbilicus, in mid inspiration.
Your abdominal circumference in Centimeters
Measure at the level of 2 inches above your umbilicus, in mid inspiration.
What is your average blood pressure range?
You may have had this taken at your surgery in the past year.

Do you take any prescribed medications?*
- No
- Yes
Medication detail if Yes
What medications are you taking? Name, dosage, what for. Eg., candesartan (Amias) 5mg for blood pressure and diabetes, atorvastatin 20mg for cholesterol and blood pressure, etc. Include hormones here.
Do you take any supplements?*
- No
- Yes
Supplements detail if Yes
Include vitamins, nutrients, herbals etc bought over the counter, with name and dose Eg. Vitamin D 3000 IU daily, Magnesium 50mg etc

Surgical history
Studies have shown that any operation could impact your body's response to illness and infection. Remember to include plastic surgery, bowel surgery, C-sections, fracture plating, joint replacement, cosmetic surgery like eyelids or facelifts here and approximate year of the operation.
Investigations: Lab tests, Imaging and Screening
If you had blood tests in the last 2 years for your iron, kidney, liver, thyroid, vitamin D, B12, folate, blood sugar, or anything else, please include it here, and whether you were told about your results. Including any screening, smear, mammogram, psa, etc

Allergies
Any Allergies?*
- No
- Yes
Allergies detail if Yes
Please include both medical and non-medical, for example: medical allergies to penicillin, non-medical hay-fever, animal fur. Describe whether you get a rash, wheezing, etc.
Any history of Anaphylaxis?*
Anaphylaxis is a serious allergic reaction to some medications, foods like peanuts, or bites and stings such as bee stings. There is swelling of the tongue, difficulty breathing, and you may have needed an adrenaline/ Epipen injection.
- No
- Yes
Anaphylaxis details if Yes
Please include what caused the anaphylaxis (if known), eg., shellfish, penicillin; and what happened - needed epipen, ambulance etc.
Any general comments or questions
Please include any symptoms you have or questions about anything not covered here. I will take your comments into account while working out your safety and risk matrix.

Patient Declarations
I confirm that I have answered all the above questions truthfully*
Should I experience any changes in my medical history, I will immediately inform the clinic*
I understand that any weight loss treatment MUST be used in conjunction with a reduced calorie diet, and increased physical activity for best results.*
I agree to record my daily food intake and physical activity*
I agree to follow the guidelines provided*
I confirm that no guarantees for weight loss have been given, and that results will vary from individual to individual. I am also aware that around 1 - 2% of people do not respond to treatment, but the reason for this is unknown, and I accept this possibility*
I wish to commence weight loss programme if found suitable following my consultation, and I consent to treatment*
Patient Signature*
Print your name here*

This form is intended to help identify and assess your risk of metabolic syndrome, overweight and obesity

Is my personal information safe?

Step 1 of 16

What this assessment aims to do:

Protecting your data

Terms and conditions

What information is being asked for:

About you

Could you be at risk of metabolic syndrome?

What is metabolic syndrome?

So what can you do about it?

Ethnicity and BMI risk factors

Height

Weight

Medications that you may be on which could affect weight management

Past and current Medical History

Family History and Familial Diseases

About your Lifestyle

Starting your weight loss journey

Allergies

Patient Declarations

Is this the right time for you to start a treatment programme?