Skin and Drip - Mounjaro Eligibility Consultation

Personal Information

Full Name

Date of Birth

Gender

Height (cm) Example: 170.5 cm

Weight (kg) Example: 75.5 kg

BMI (auto-calculated)

Contact Information

Email

Phone Number

Address

GP (General Practitioner) Name (if applicable)

Medical History

Have you been diagnosed with Type 2 Diabetes?

Yes

No

Do you have a history of any of the following:

Thyroid cancer (especially medullary thyroid carcinoma)

Pancreatitis

Gallbladder disease

Severe gastrointestinal disease

Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)

Do you have any known allergies to medications?

Yes

No

Medical History (Continued)

Are you currently taking any medications?

Yes

No

Do any of the following apply to you?

Heart/cardiovascular condition (excluding heart failure)

Elevated cholesterol

Osteoarthritis

Sleep apnea

Non-alcoholic fatty liver disease

Do any of the following serious conditions apply to you?

Pancreatic cancer or family history

Impaired liver function

Kidney disease (especially end-stage)

Heart failure

Medullary thyroid cancer or a family history

Multiple Endocrine Neoplasia (MEN) syndrome

Medical History (Continued)

Do any of the following gastrointestinal/metabolic conditions apply to you?

Diabetic retinopathy

Inflammatory bowel disease

Coeliac disease

Chronic malabsorption syndrome

Chronic pancreatitis

Have you ever experienced or currently have an eating disorder (e.g. bulimia)?

Yes

No

Lifestyle Assessment

How many times per week do you exercise?

I do not exercise

1–2 times per week

3–4 times per week

5 or more times per week

On a typical day, how many meals do you eat?

1 meal

2 meals

3 meals

More than 3 meals

Do you smoke or use alcohol?

Yes

No

How many hours do you sleep per night?

Less than 5 hours

5–6 hours

7–8 hours

More than 8 hours

Weight Loss History

Have you tried any of the following in the past 12 months?

Dieting

Exercise

Other weight loss medications

Bariatric surgery

How much weight have you lost or gained in the past 6 months?

I have gained weight

No significant change

I have lost less than 5 kg

I have lost more than 5 kg

Treatment History

Have you taken Ozempic or Mounjaro before?

No

Yes

Motivation & Goals

Why do you want to start Mounjaro?

To lose weight for health reasons

To improve physical appearance

Doctor or specialist recommendation

I've tried other methods without success

What are your weight loss goals?

Lose 5–10 kg

Lose 11–20 kg

Lose more than 20 kg

Reach a specific target weight

Are you willing to commit to regular check-ins and lifestyle changes?

Yes

No

GP Communication & Consent

Would you like us to inform your GP/Doctor?

Yes

No

Do you believe you have the ability to make healthcare decisions for yourself?

Yes

No

Please confirm that you have read and understood the following information:

This programme is not designed to monitor comorbidities.
It is recommended to see your GP every 3–6 months.
Mounjaro is a weekly injection (abdomen, thigh or upper arm).
Possible side effects: nausea, diarrhoea, headache, bloating, constipation, etc.
You must read the "Patient Information Booklet".
A follow-up consultation must be completed monthly.

I agree

Personal Information

Contact Information

Medical History

Medical History (Continued)

Medical History (Continued)

Lifestyle Assessment

Weight Loss History

Treatment History

Motivation & Goals

GP Communication & Consent

Thank You!