Tirzepatide F/U Questionnaire

Name

First NameLast 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?

2. Are you using one of these diets currently?

3. Have you ever tried exercise or increased physical activity to lose weight?

4. Have any of these conditions improved or resolved since our last visit?

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.