RAF - Weight Loss (Mounjaro)

Weight Loss Assessment Form
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

First Line of Address

Street Address 2

CityCountry

Postcode
Email*
Please check your email address is correct
Phone Number*
Medical History
Are you aged between 18-75 years?*

YesNo
Height
Weight
What sex were you assigned at birth?*

MaleFemale
Do you suffer from any of the following?*

Severe Liver or kidney impairmentHeart failureHistory of PancreatitisMultiple endocrine neoplasia type 2Active cancerType 1 diabetes or diabetic retinopathyPersonal or family history of medullary thyroid cancerA current eating disorder or a history of an eating disorder? (e.g., anorexia, bulimia, binge eating disorder)History of gallbladder problemHistory of Inflammatory bowel disease or gastroparesisNone of the above
Have you been diagnosed with any of these medical conditions?*

Type 2 diabetesHigh blood pressureHigh cholesterolErectile dysfunctionSleep apnoeaAsthmaOsteoarthritisChronic back painDepressionPCOSFatty liver diseaseNone of the above
Are you taking any of the following medications?*

Oral contraceptive tabletInsulinGLP-1 receptor agonistSulphonylureasLithium tablets or capsulesDigoxinWarfarinMethotrexate (tablets only NOT injections)CiclosporinCarbamazepinePhenytoinOtherNone of the above
Please specify*
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?*

YesNoN/A
Are you breast-feeding?*

YesNoN/A
Do you have any thyroid conditions?*

YesNo
Please provide details*
Have you previously tried or are you currently taking medication to help aid weight loss?*

YesNo
Please specify*
Have you received advice from a weight management counsellor before?*

YesNo
This medication may not be suitable for you, please contact us for further advice, by email: info@myprivatechemist.com, or phone: 02039879202.
Collection from:

My Private Chemist

Longcroft House

2-8 Victoria Avenue

EC2M 4NS
Should be Empty:

Weight Loss Assessment Form

Patient Information

Medical History