Weight Loss Assessment

Full Name

Date of Birth

Address

Telephone

What is your GP Name and Address?

What is your Gender?

Male Female Prefer not to say

What is your ethnicity?

Asian or Asian British Black, African, Caribbean or Black British Middle Eastern Mixed or multiple ethnicities (incl. Asian, Black, Middle Eastern) White (incl. White British, White Irish and any Other White) Other Prefer not to say

Are you aged 18 - 74?

Yes No

What is your Height?

What is your Weight?

Are you pregnant, breastfeeding or planning pregnancy?

Pregnant Breastfeeding Planning Pregancy No

Have you ever experienced any side effects from: Mounjaro (Tirzepatide); Wegovy/Ozempic (Semaglutide) or Saxenda/Victoza (Liraglutide)?

Yes No Never had them before

Do you have any of the following gallbladder issues?

Gallblader infection (Cholecystitits) Blocked Bile Flow (Cholelithiasis) Gallstones that have not been removed Gallbladder Surgery in the past 12 months None of the above

Have you ever had an eating disorder?

In the past 12 months, have you had bariatric weight loss surgery or gastric band procedure?

Yes No

Have you been diagnosed with Type 1 Diabetes?

Yes No

Have you been diagnosed with Type 2 diabetes and using Insulin?

Yes No

Have you been diagnosed with Type 2 Diabetes and using oral tablets other than Metformin?

Yes No

Do you have a personal or family history of thyroid cancer, medullary thyroid cancer or multiple endocrine neoplasia type 2 (MEN2) syndrome?

Yes No

Are you using any thyroid medications?

Yes No

Please tick to confirm that you agree with the following:

Mounjaro and Wegovy, may increase the risk of pancreatitis, gallbladder issues, and the formation of gallstones. If you experience severe abdominal pain (particularly if it radiates to your back), vomiting, or any worsening of symptoms, it is important to seek immediate medical attention by calling 999 or attending your nearest A&E department.

Severe diarrhoea lasting more than 24 hours or vomiting within 3 hours of taking your oral contraceptive pill can reduce its effectiveness. You may require a repeat dose, and it is advised to call NHS 111 for medical guidance to help prevent unplanned pregnancy.

These treatments may be linked to changes in mood. If you experience any new or concerning symptoms—such as low mood, suicidal thoughts, thoughts of self-harm, or other mental health issues—you should stop treatment immediately and seek advice from your doctor.

If you are sexually active, please be aware that Mounjaro may reduce the effectiveness of the oral contraceptive pill. To prevent unplanned pregnancy, it is recommended that you use an additional form of contraception, such as condoms, an IUD, or an implant, while taking Mounjaro.

Mounjaro and Wegovy should not be used in combination with any other weight-loss medications or products.

Do you agree with the following?

I confirm that the information I have provided is true and accurate to the best of my knowledge and I will contact Pharma Clinic or GP if I experience any side effects from the treatment. I understand that this information will be used by the prescribers to assess whether it is appropriate to supply the requested medication. I acknowledge that providing inaccurate or incomplete information may result in the refusal of treatment or the supply of medication that may not be suitable for me. I agree to Pharma Clinic notifying my GP in regard to this treatment, agree for the collection, processing and storage of my personal data for the purpose of treatment

Please upload a picture of your ID (not expired)

Please upload few pictures of you full body wearing tight fitted clothing so our healthcare professionals can assess appropriately. (Please do not cover your face as we need to verify against the ID)

Please upload proof of your last supply if you are choosing a higher strength than 2.5mg.

Weight Loss Assessment

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