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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. What is your Date of Birth?
Day
Month
Year

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

pregnancy
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

  1. Please select any items that apply (multi select)

eating disorder

  1. 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.

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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