Mounjaro Weight Loss Consultation

Step 1 of 6

16%

Name(Required)

Prefix First Last

Date Of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Phone Number(Required)

Email(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

NHS Number (If Known)

Registered GP

This will be used to verify weight and medical history.

GP Postcode

GP Telephone Number (If Known)

Ethnicity

Asian or Asian British

Black, Black British, Caribbean or African

Mixed or multiple ethnicities with an Asian, Black or Middle Eastern Background

White

Middle Eastern

Other Ethnic Group

Prefer Not To Say

Upload one form of ID (You Can Do This Later)

Max. file size: 256 MB.

Height (cm)(Required)

Please enter a number less than or equal to 300.

Weight (kg)(Required)

Please enter a number less than or equal to 500.

Height (m)

Your BMI

Please Note

You may not be eligible for weight loss treatment. Please consult with a healthcare provider for advice

Do you have any of the following conditions?(Required)

Prediabetes

Heart disease

High blood pressure

High cholesterol

Obstructive sleep apnoea

None of the above

Do you have any of the following conditions?(Required)

Type 1 Diabetes

Type 2 Diabetes

Diabetic Gastroparesis

Inflammatory Bowel Disease (IBS)

Ketoacidosis

Obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain

Severe renal impairment

Severe hepatic impairment

Pancreatitis

Cholelithiasis and cholecystitis (include history), Gall bladder problems or gallstones

Thyroid disease or medullary thyroid cancer (include history)

Any eating disorders

Heart Failure

Sustained increase in resting heart rate

Severe gastrointestinal disease, e.g. severe gastroparesis, chronic malabsorption syndrome

Had bariatric surgery in last 12 months

None of the above

Do you take any medications? (Please include prescribed or non prescribed medications)(Required)

Yes

List Medications

Do you have any allergies?(Required)

Yes

Please Note: Do you have any allergy or any hypersensitivity to tirzepatide or any excipients in Mounjaro Kwikpen pen? Excipients: Sodium phosphate dibasic heptahydrate Sodium chloride Concentrated hydrochloric acid, and sodium hydroxide (for pH adjustment) Glycerol Phenol Benzyl Alcohol Water for injections

List Allergies

Are You Currently Pregnant

Yes

Are You Currently Breastfeeding?

Yes

Are You Currently Trying To Conceive?

Yes

Have you previously used any weight loss medication?(Required)

Yes

Which of the below have you used or are currently using?(Required)

Wegovy

Ozempic

Mounjaro

Orlistat/Xenical

Other

Which Strength of Wegovy?(Required)

0.25 mg

0.5 mg

1 mg

1.7 mg

2.4 mg

Which Strength of Mounjaro?(Required)

2.5 mg

5 mg

7.5 mg

10 mg

12.5 mg

15 mg

Which Strength of Ozempic?(Required)

0.25 mg

0.5 mg

1 mg

Please State

When was your last dose taken?(Required)

Less than a month

1 - 3 months

3 months +

Have you previously taken any weight loss medications (e.g. Mounjaro, Wegovy, Ozempic) and experienced side effects?(Required)

Yes

If yes, please describe them.

Have you tried diet & exercise before?(Required)

Yes, with success

Yes, with out success

How often do you exercise?(Required)

Daily

3 - 5 times a week

1 - 2 times a week

Rarely or Never

How would you describe your diet?(Required)

Healthy & Balanced

Moderate but inconsistent

Poor diet choices

I follow a specific diet plan

Details of specific diet plan

Do you smoke?(Required)

Yes

How often do you drink alcohol?(Required)

Occasionally (less than 5 units/week)

Frequently (more than 5 units/week)

Daily

I have read the patient information leaflet, especially refer to section 4 on how to use the preparation. https://www.medicines.org.uk/emc/files/pil.15481.pdf(Required)

Tick to confirm

I understood that there is a risk of hypoglycaemia with Mounjaro if I am taking anti-diabetic drugs or using insulin, and I have been advised to self-monitor blood sugar level regularly. I have been advised what I should do if I suspect a hypoglycaemic episode.(Required)

Tick to confirm

I understand that Mounjaro may reduce the effectiveness of oral contraceptives and that you must use additional contraceptive measures, such as a barrier method (e.g. condoms), or switching to a non-oral form of contraception (e.g. IUD’s and implants) for 4 weeks after initiating Mounjaro and for 4 weeks following each dose increase.(Required)

Tick to confirm

I understand that Mounjaro should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child.(Required)

Tick to confirm

I understood that I need to be assessed the efficacy of the treatment after 6 months, treatment will be discontinued if it does not achieve more than 5% weight loss at that time.(Required)

Tick to confirm

I understand the risk of pancreatitis, gall bladder issues, and gallstones associated with these medications, and that abdominal pain should be reported to a doctor.(Required)

Tick to confirm

I understand that injectable weight-loss medications should not be used in combination with other weight-loss drugs.(Required)

Tick to confirm

I understand that if you develop neck lumps or a hoarse voice while using this medication, you should stop and contact your doctor.(Required)

Tick to confirm

I understand both weight loss and injectable weight loss treatment have been associated with lowering of mood, if experiencing depression, thoughts of self-harm or other mental health issues should seek medical advice.(Required)

Tick to confirm

I agree to the following: I have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health I understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable I will inform your doctor about any unusual side effects The treatment is solely for my own use I will read the patient information leaflet supplied with your medication and understand the titration schedule, actions to take if a dose is missed, correct self-injection technique, and proper storage requirements for the medication I will not exceed the maximum prescribed dose I understand that you should follow up with your GP at least once annually for ongoing monitoring and care I confirm you have the capacity to make decisions about your own health(Required)

Tick to confirm

I understand that we will be notifying your GP(Required)

Tick to confirm

I confirm that my information is accurate.(Required)

Tick to confirm

I consent to PPRX accessing my summary care records (SCR)(Required)

Tick to confirm

I understand that even if treatment is initiated, in order to lose weight there needs to be a reduced-calorie diet and an increased physical activity action in place.(Required)

Tick to confirm

Please write any other information you would like the prescriber to know.

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Weight Loss Consultation Form PGD

Please Note