Assessment Progress

1About You
2Your Medical History
3Acknowledgements

Assessment

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1About You

For temperature control reasons we are currently only able to deliver treatment to a limited number of postcodes. View the available postcodes here.

Please confirm the postcode you intend to use for delivery. Click search to check if we can service your area. *

Are you aged between... *

Saxenda may not be suitable for those aged over 65. Requests for Saxenda in those over 65 will be refunded.

Wegovy and Saxenda may not be suitable for those aged over 75. Requests for Wegovy or Saxenda in those over 75 will be refunded. Mounjaro has been clinically evaluated for safety in those aged up to 84.

What was your sex registered at birth? (i.e your biological sex) *

Are you pregnant, breastfeeding or trying to conceive (now or in the near future)? *

NoYes

Are you currently using oral hormonal contraception? *

NoYes

If using Mounjaro - I understand that I must use an additional barrier method of contraception (such as condoms) when starting treatment or for 4 weeks every time I increase my dose, as Mounjaro can reduce the effectiveness of my hormonal contraception. *

Confirm

Please enter your height (cm) *

Please enter your weight (kg) *Your weight must be from the last 7 days* *

Please note, we may contact you to ask you to provide visual evidence of your current weight.

BMI

Do you know your current waist circumference? *

NoYes

[Enter waist measurement] *

What is your ethnicity? (This will help our prescribers gain a better idea about your risk in relation to your weight) *

Please provide more information below. *

Do you have any of the following conditions? *

Severe heart failureKidney impairmentDiabetic retinopathyPancreatitis (current or previous issues)GastroparesisAny inflamatory bowel disease (such as Ulcerative colitis or crohns) not Irritable Bowl Syndrome (IBS)History or family history of Thyroid cancer, medullary thyroid cancer or MEN2Any active cancer, current chemotherapy or radiotherapyNone of the above

Do you have gallbladder or bile duct issues? *

NoYes

Could you please provide more information about your gallbladder issues? *

Please provide more information below. *

When did you have surgery to remove your gallbladder? *

Do you have liver impairment? *

NoYes

Do you have any of the following liver conditions? If suitable, people with certain medical conditions may be prescribed weight loss medicines at a lower BMI than other patients. *

Please provide more information below. *

Do you have diabetes? *

Advisory - It's important to keep us informed if your doctor starts you on any medication relating to your pre-diabetes/diet controlled diabetes, as this may impact your treatment.

Do you use any of the following medication to treat your diabetes? *

Please provide more information below. *

People with weight-related medical conditions may be prescribed weight loss medicines at a lower BMI than other patients, if suitable. Please let us know if you have any of the following weight-related conditions: *

Do you have any medical conditions? *

NoYes

Please list your medical conditions below. *

Have you ever made yourself sick (vomit) to control your shape or to lose weight? *

NoYes

In the last year, have you taken laxative medication in order to lose weight? *

NoYes

Do you worry that you have lost control over how much you eat? (i.e. you have eaten an unusually large amount of food and have had a sense of loss of control at the time?) *

NoYes

Would you say that food or image dominates your life *

Do you ever eat in secret? *

NoYes

2Your Medical History

Do you take any medication (From your GP, over the counter or herbal medication)? *

NoYes

Please list any prescription, over the counter or alternative medicines you are taking, including the dose. *

Do you have any allergies? *

NoYes

Please provide more information below. *

Have you had any surgery in the past 3 months? *

NoYes

Please provide more information below. *

Have you ever been diagnosed with an eating disorder (such as anorexia, binge eating disorder or bulimia) by a healthcare professional? *

NoYes

How much exercise do you undertake each week? *

In order to get the best weight loss results with treatment, you do need to use it in conjunction with regular exercise of more then 60 minutes per week.

Are you CURRENTLY using any of the following (You have used a dose within the last 2 weeks) *

Did you receive your last supply from Simple Online Doctor? *

How long have you been using Wegovy? *

What was your weight when you started Wegovy? *

Would you like to continue with Wegovy? *

Please confirm that you understand the following: If you are on 0.25mg or 0.5mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Saxenda. If you are on 1mg, 1.7mg or 2.4mg you must stop treatment for at least 4 weeks prior to starting Saxenda. *

Confirm

Please confirm that you understand the following: If you are on 0.25mg or 0.5mg of Wegovy, you must stop treatment for at least 2 weeks prior to starting Mounjaro. If you are on 1mg, 1.7mg or 2.4mg you must stop treatment for at least 4 weeks prior to starting Mounjaro. *

Confirm

What dose did you last use? *

Would you like to remain at your current dose, increase or reduce to the next dose? *

Please tell us more about why you would like to stay at your current dose as opposed to increasing (such as side effects, acheiving weight aims, achieved maintenance dose or cost) *

Please tell us more about why you would like to reduce your dose (such as side effects or cost) *

Are you currently taking or planning to increase to the 1.7mg or 2.4mg strength? *

NoYes

Please upload evidence of previous supply. Evidence can be: your Wegovy box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP or a copy of your previous prescription. Your name, the name of the medication, the date of supply and the strength should be clearly visible. Without the correct evidence we may only be able to prescribe you lower starting doses. *

How long have you been using Ozempic? *

What was your weight when you started Ozempic? *

What dose did you last use? *

We do not offer Ozempic for weight loss - would you like to switch to any of the following? *

Please confirm you understand the following: If you are on 0.25mg or 0.5mg of Ozempic, you must stop treatment for at least 2 weeks prior to starting Saxenda. If you are on 1mg (or a higher unlicensed dose) you must stop treatment for at least 4 weeks prior to starting Saxenda. *

Confirm

Please confirm you understand the following: If you are on 0.25mg or 0.5mg of Ozempic, you must stop treatment for at least 2 weeks prior to starting Mounjaro. If you are on 1mg (or a higher unlicensed dose) you must stop treatment for at least 4 weeks prior to starting Mounjaro. *

Confirm

Would you like to remain at your current dose, or increase to the next dose? *

Please tell us more about why you would like to stay at your current dose (such as side effects, acheiving weight aims or cost) *

Please tell us more about why you would like to reduce your dose (such as side effects, acheiving weight aims or cost) *

Are you using over a 1mg dose of Ozempic once weekly? *

NoYes

Please upload evidence of previous supply. Evidence can be: your Ozempic box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP or a copy of your previous prescription. Your name, the name of the medication, the date of supply and the strength should be clearly visible. Without the correct evidence we may only be able to prescribe lower starting doses. *

Did you receive your last supply from Simple Online Doctor? *

How long have you been using Mounjaro? *

What was your weight when you started Mounjaro? *

Would you like to continue with Mounjaro? *

Please confirm you understand the following: If you are on 2.5mg, 5mg or 7.5mg of Mounjaro, you must stop treatment for at least 2 weeks prior to starting Wegovy. If you are on 10mg, 12.5mg or 15mg of Mounjaro you must stop treatment for at least 3 weeks prior to starting Wegovy. *

Confirm

Please confirm you understand the following: If you are on 2.5mg, 5mg or 7.5mg of Mounjaro, you must stop treatment for at least 2 weeks prior to starting Saxenda. If you are on 10mg, 12.5mg or 15mg of Mounjaro you must stop treatment for at least 3 weeks prior to starting Saxenda. *

Confirm

Please upload evidence of previous supply. Evidence can be: your Mounjaro box with a pharmacy/dispensary label, a letter from your previous Pharmacy/GP or a copy of your previous prescription. Your name, the name of the medication, the date of supply and the strength should be clearly visible. Without the correct evidence we may only be able to prescribe you lower starting doses. *

Did you receive your last supply from Simple Online Doctor? *

Have you used Saxenda within the past 3 days? *

NoYes

How long have you been using Saxenda? *

What was your weight when you started Saxenda? *

Would you like to continue with Saxenda? *

Please confirm you understand the following: If you are on Saxenda, you must stop treatment for at least 3 days prior to starting Wegovy. *

Confirm

Please confirm you understand the following: If you are on Saxenda, you must stop treatment for at least 3 days prior to starting Mounjaro. *

Confirm

What dose did you last use? *

If you are still increasing your dose to 3.0mg daily, continue to do so as directed.

Saxenda is recommended for use at the 3.0mg maintenance dose for best results. If you are remaining at lower doses, this is considered off-label (see what this means here). Due to delivery limitations, we do not recommend staying at lower doses as it can increase the likelihood of treatment expiry if delivery is delayed - if this does occur Simple Online Doctor is not liable for replacing or refunding any expired medication. Please confirm you understand this information.

Confirm

If you are still increasing your dose to 3.0mg daily, continue to do so as directed.

Confirm

If you are still increasing your dose to 3.0mg daily, continue to do so as directed.

Confirm

If you are still increasing your dose to 3.0mg daily, continue to do so as directed.

Confirm

Would you like to remain at your current dose, increase or reduce to the next dose? *

Please tell us more about why you would like to stay at your current dose (such as side effects, achieving weight aims, achieving maintenance dose or cost) *

Please tell us more about why you would like to reduce your dose (such as side effects, acheiving weight aims or cost) *

Did you receive your last supply from Simple Online Doctor? *

When did you last use Xenical/Orlistat? *

What was your weight when you started Xenical/Orlistat? *

Would you like to continue with Xenical/Orlistat? *

I agree to discontinue Xenical/ Orlistat prior to starting Wegovy. *

Confirm

I agree to discontinue Xenical/ Orlistat prior to starting Saxenda. *

Confirm

I agree to discontinue Xenical/ Orlistat prior to starting Mounjaro. *

Confirm

If you wish to continue Xenical/ Orlistat, you will not be approved for GLP-1 treatment as multiple treatments for weight loss is not recommended. If you wish to switch to GLP-1 treatment, continue this assessment and request. If you wish to stay on Xenical/ Orlistat treatment, complete the assessment found here.

What weight loss medicine are you currently taking? *

When did you last use the weight loss medication you mentioned? *

What was your weight when you started taking the medication? *

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide more information below. *

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

NoYes

Please enter the email address of your GP clinic *

3Acknowledgements

I understand that Wegovy, Mounjaro and Saxenda are used as an injection under the skin (subcutaneous injection). I will not inject it into a vein or muscle. The best places to give the injection are the upper arms, stomach or upper legs. I will ensure to drink plenty of fluids to avoid dehydration. I can find detailed instructions on using Wegovy/Mounjaro/Saxenda in the consumer medicine information in the box. I understand that the best and safest weight loss outcomes are achieved by slowly and carefully titrating the dose as per the dose escalation schedule to gain the maximum benefit from the medication. *

Confirm

I understand that to ensure my order is processed for delivery before the Wednesday cut-off I need to allow enough time for my order to be processed. If you have an existing approval and repeats with our service we recommend placing the order by 2 PM AEST on Tuesday. If you do not have an existing script we recommend placing the order by 2 PM AEST Monday to allow enough time to book your call with the doctor. Orders that do not allow enough time for the doctor's approval will not be sent until the following Monday due to the medication being temperature controlled. This may change around public holidays. You will be notified with tracking information by email once your order has been sent. *

Confirm

I understand I should use one weight loss product at any one time I understand that if I experience any troublesome side effects from Wegovy/Mounjaro/ Saxenda, I can contact Simple Online Doctor, my GP, or another healthcare professional for advice. I confirm that I will read about the side effects in the consumer medicine information. *

Confirm

I confirm this treatment is for me, and I consent to this treatment.
If Wegovy/Mounjaro/Saxenda does not help me realise my weight loss aims, I will consult my GP for further advice.
I take responsibility to inform Simple Online Doctor and/or my own regular doctor of any changes in my circumstances.
I agree to the Simple Online Doctor terms and conditions.

Confirm

I confirm that all the above information is truthful and accurate. I agree to inform Simple Online Doctor of any change to my health as soon as possible, as I understand this could impact the suitability of the medication I am being prescribed. *

Confirm

I agree to stop treatment and inform Simple Online Doctor and/or seek medical attention if I experience severe dehydration, e.g. dark urine, confusion, blood in stool or vomit, diarrhoea lasting longer than 72 hours, or being unable to keep food down without vomiting/diarrhoea. *

Confirm

Wegovy will last for 42 days outside of the refrigerator (2°C to 8°C) - each pack contains 28 days of treatment. Mounjaro will last for 30 days outside of the refrigerator (2°C to 8°C) - each pack contains 28 days of treatment. Saxenda will last for 30 days outside of the refrigerator (2°C to 8°C) - the starter pack contains 25 days of treatment (2 pens) and the maintenance pack contains 24 days of treatment (4 pens). The treatment will be sent in temperature controlled packaging. Medicine expiry dates will be provided as part of your order if unexpected delays occur. This medication requires a signature on receipt of delivery. If unavailable, your parcel is taken to a post office for collection. Simple Online Doctor cannot be held responsible for medication expiring due to failure to collect your medicine, as a result of a delay due to redirecting your order in transit or as a result of an incorrect delivery address. The delivery time is 1-2 business days on average in the allowed postal areas. *

Confirm

During your consultation the doctor may approve repeats of the medication for a certain time frame, subject to the specific treatment and your current health. Repeats during this period will be stored in your account and can be processed without the need for another consultation. Please confirm you understand this information. *

Confirm

If we are unable to assist via a telehealth consultation, you may be asked to seek alternative medical care such as that of a doctor in person. If this occurs you will receive a refund on your request. *

Confirm

Simple Online Doctor is a private clinic; the consultation and medication may be eligible for rebates through your private health cover, but are not covered by Medicare or the PBS. We conduct regular price reviews to ensure we are providing among the best value online. *

Confirm

As per Australian telehealth guidelines, all first time patients, those requesting a new treatment or those looking to renew a prescription must have a brief call with one of our doctors. Do you have reliable access to a video call device (phone/computer) or a phone to accept this call? *

NoYes

You require reliable access to the internet on a device which you can use to have a video consultation with the doctor in order to be suitable for telehealth. Please refer to your regular GP in person.

Did you have difficulty understanding the English that is written in this assessment, affecting your ability to provide accurate answers or do you require language interpretation during a verbal consultation? *

NoYes

As you have difficulty understanding the assessment and or require interpretation services, you will be required to have an interpreter with you during your consultation with the doctor. You can access these services at Translating and Interpreting Services. Please confirm that you agree to organise an interpreter for your consultation. *

Confirm

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1About You

2Your Medical History

3Acknowledgements

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Assessment

1About You

2Your Medical History

3Acknowledgements

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