Wegovy Eligibility Quiz

1
Name* This field is required.
First Name
Last Name
2
* This field is required.
Email
Phone Number
Age
Date of Birth
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Before we begin, please confirm the following:* This field is required.
I am over 18 years old
I am answering for myself and truthfully
I have already trieddiet and exercise to lose weight
I will be the sole user of any treatment provided
I agree to Mounjaro's Terms & Conditions and Privacy Policy
5
What is your height and weight?* This field is required.This information helps us understand your Body Mass Index (BMI) and suitability for Mounjaro
Height
Weight
6
What is your goal weight?* This field is required.
Where do you want to be? This helps us visualize your journey and set realistic goals
7
What is your biological sex?
Healthy BMI ranges differ based on body structure. We appreciate this may not align with your gender identity
8
Have you been diagnosed with diabetes?* This field is required.Note: Diabetes treatments can impact the effectiveness of weight loss medications
Yes
No
I'm not sure
9
If you were born female, do you have plans to start or grow your family within the next 3 months?* This field is required.Note: Weight loss medication has a high risk of causing birth defects and can interfere with some methods of birth control
Yes
No
10
Do any of the following conditions apply to you? (Select all that apply)* This field is required.
I am currently pregnant or breastfeeding
I have been diagnosed with an eating disorder, or I suspect I might have one
I have a history of pancreatitis
I have severe heart failure or cardiomyopathy
I have liver or kidney disease
I have gallbladder disease
I have a family history of thyroid cancer
I have been treated for cancer
I have a seizure disorder such as epilepsy
I have had a bariatric operation such as a gastric band or sleeve surgery
None of these apply to me
11
Have you ever taken any of the following medications for weight loss? (Select all that apply)* This field is required.
Ozempic
Wegovy
Saxenda
Rybelsus
Other
I’ve never taken any weight loss medication
12
Do you currently take any other medications? (Select all that apply)* This field is required.
Levothyroxine
Warfarin
Monoamine Oxidase (MAO) inhibitors in the last 14 days
Other prescribed medications
Over-the-counter medications or supplements
13
Do you have any allergies?* This field is required.
Include all allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes, etc
14
How long have you struggled with your weight?* This field is required.
Less than 12 months
1-5 years
5-10 years
Most of my life
I’ve never struggled with my weight
15
What have you tried in the past to lose weight? (Select all that apply)* This field is required.
Exercise or being more active
Dieting
Calorie counting
Weight loss programs
Weight loss supplements
16
What challenges have you faced when trying to lose weight? (Select all that apply)* This field is required.
I lose motivation
I find it difficult to be consistent
I do not have enough time
I lose weight, then put it back on
I’m not sure what I should be eating
I get cravings or snack too much
Injury/illness makes it difficult
I feel uncomfortable exercising in front of others
17
Include any medical conditions, procedures, or surgeries you didn't mention earlier* This field is required.
18
Enter Your GP Details* This field is required.Patient Notice: It is our policy to inform your GP when patients start prescription medication for weight management. This is to help your GP avoid any interactions with other medications they may prescribe for you. Please tick 'I Agree' below to give us your permission to do so.
GP Name
GP Phone Number
Your GP Address Details
19
I Agree, I agree on Pharma Aesthetics Contacting My GP* This field is required.
I agree
20
Any other questions or comments for us or the prescriber?
21
By pressing "Submit", you're confirming you understand that* This field is required.
You can only take one weight loss medication at a time
You will review the patient information leaflet that comes with your medication
You will contact us and your Primary Care Provider if you experience any side effects or if your medical conditions change during treatment
The treatment is for your personal use only
You have answered all questions truthfully and accurately
Our prescribers use your answers to guide their decisions, and providing incorrect information can impact your health
22
Should be Empty: