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Eligibility Assessment

Clinical Questionnaire - 1/2

Leaner AVO follows strict clinical protocols to ensure patient safety.

Your responses allow our doctors to determine your eligibility for medical programs. Please ensure all information is accurate and complete.

1. Are you currently pregnant, breastfeeding or planning to become pregnant in the near future?

Single choice
I am pregnant
I am breastfeeding
I am planning to become pregnant within the next 6 months
I could be pregnant (I'm not sure)
No - I am not pregnant, breastfeeding or planning to become pregnant
Not Applicable / Male

2. Have you ever been diagnosed with any of these health conditions?

This is important, as these conditions may cause serious interactions with some weight loss medications.

Multi choice

3. Do you have a family history (parents and/or siblings) of the following conditions?

Multi choice

4. Please select any items that apply

Multi choice

Patient Note: This is a pre-screening assessment only and does not constitute medical advice or a formal consultation. Eligibility is subject to physician review. Submitting this form acknowledges consent to our clinical assessment protocol.

By submitting this form, you acknowledge that your health data is collected for clinical review in accordance with our privacy policy and Australian healthcare regulations. Your data is processed securely via our medical portal.

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