Tirzepatide F/U Questionnaire
Name
*
First Name
Last Name
Email
*
Weight (lb)
Height (inches )
Waist Circumference (inches )
BMI
BMI 18.49 or less
18.5 to 24.99 BMI
25 to 29.99 BMI
30 or over BMI
Your BMI:
{bmi1849}
{bmi184937}
{185To}
{25To}
1. Have you been diagnosed with any of these since are last visit?
*
Pancreatitis
MEN/MTC/Thyroid CA
Family Hx of MEN/MTC/Thyroid CA
Bulimia
Anorexia
N/A
2. Are you using one of these diets currently?
Reduced Calorie Diet
Noom
Jenny Craig
Intensive Behavior Therapy
Keto Diet
Intermittent Fasting
Low Carb Diet
Mediterranean Diet
Whole 30
Weight Watchers
Nutrisystem
Optavia
Registered Dietitian
N/A
3. Have you ever tried exercise or increased physical activity to lose weight?
Yes
No
4. Have any of these conditions improved or resolved since our last visit?
Acanthosis Nigricans
Obstructive Sleep Apnea
Pre-Diabetes
Diabetes
High Blood Pressure
Coronary Disease/ Blockage
Have you ever had a Heart Attack/ Stroke/TIA
Congestive Heart Failure
Hyperlipidemia/ High Cholesterol
Urinary Incontinence
GERD
Osteo Arthritis
Skin Fold Infections
Depression related to your Weight
Gall bladder removal
Kidney Stones
Substance Use related to your weight
Anxiety related to your Weight
Poly-Cystic Ovary Disease
Metabolic syndrome
Fatty Liver
Previous Bariatric Surgery
N/A
Tirzepatide Dosing
*
Start with (25 units) 2.5 mg injected once weekly for 4 weeks then increase to 50 units (5 mg) injected once weekly. Increase the dosage in 25 unit (2.5 mg) increments after at least 4 weeks on the current dose. The recommended maintenance dosages are 5 mg, 10 mg, or 15 mg injected subcutaneously once weekly. During treatment continue Reduced Calorie Diet, Protein 1g/kg/day to avoid lean muscle mass and Moderate Physical Activity 150 minutes a week.
Tirzepatide Counseling
*
Common side effects of Tirzepatide include nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, and stomach pain. Serious risks involve thyroid tumors, pancreatitis, hypoglycemia, severe allergic reactions, worsening kidney problems, vision changes, and gallbladder issues. It is contraindicated in individuals with a personal or family history of medullary thyroid carcinoma, Multiple Endocrine Neoplasia syndrome type 2, or allergies to its ingredients. No safety data for pregnancy. Stop Tirzepatide at least 6 weeks prior to trying to conceive. Hold about 2 weeks prior to procedures requiring general anesthesia or a completely empty stomach.
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