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NHS Digital Weight Management Programme

Please answer the questions below if you would like to be considered for referral of the NHS Digital Weight Management Programme.

Last Updated: 12/11/2021

PLEASE ANSWER THE QUESTIONS BELOW IF YOU WOULD LIKE TO BE CONSIDERED FOR REFERRAL OF THE NHS DIGITAL WEIGHT MANAGEMENT PROGRAMME.

Please answer the questions below if you would like to be considered for referral of the NHS Digital Weight Management Programme.

WHAT IS YOUR FORENAME? *

WHAT IS YOUR SURNAME? *

ARE YOU 18 OR OVER? *

Yes No

WHAT IS YOUR EMAIL ADDRESS? *

WHAT IS YOUR DATE OF BIRTH? *

WHAT IS YOUR HEIGHT? (IN METERS) *

HOW MUCH DO YOU WEIGH? (IN KILOGRAMS) *

DO YOU HAVE A BMI GREATER THAN 30? (OR 27.5 IF YOU ARE FROM A BLACK, ASIAN, AND ETHNIC MINORITY BACKGROUND, AS PEOPLE FROM THESE ETHNIC BACKGROUNDS ARE AT AN INCREASED RISK OF CONDITIONS SUCH AS TYPE 2 DIABETES AT A LOWER BMI) *

Yes No

WHAT IS YOUR EXACT BMI? (BMI CALCULATOR- HTTPS://WWW.NHS.UK/LIVE-WELL/HEALTHY-WEIGHT/BMI-CALCULATOR/)

DO YOU HAVE DIABETES, HIGH BLOOD PRESSURE, OR BOTH? *

Yes No

DO YOU HAVE A SMARTPHONE, TABLET, OR COMPUTER WITH INTERNET ACCESS? *

Yes No

DO YOU AGREE TO BE REFERRED TO THE NHS DIGITAL WEIGHT MANAGEMENT SERVICE? *

Yes No

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