Tirzepatide Eligibility 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. Do you have or ever had?
*
Pancreatitis
MEN/MTC/Thyroid CA
Family Hx of MEN/MTC/Thyroid CA
Bulimia
Anorexia
N/A
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2. Have you ever tried one of these diets?
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. Do you have any of these medical conditions?
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
5. Do you have any of these medical conditions?
Psoriasis
Hidradenitis Suppurativa
Lipodystrophy
Acanthosis Nigricans
N/A
6. Have you gained weight as a result of taking one of these medicines?
Antidepressants (SSRIs like sertraline and paroxetine)
Antipsychotics (clozapine, olanzapine, risperidone)
Antiepileptics (alproate, carbamazepine)
Beta-Blockers (propranolol, metoprolol)
Corticosteroids (prednisone, dexamethasone)
Diabetes medications (thiazolidinediones, sulfonylureas)
Antihistamines (diphenhydramine, cetirizine)
Mood Stabilizers (lithium)
N/A
7. I have tried these medications and failed to lose weight or had a side effect you could not tolerate:
Metformin
Phentermine
Qsymia
Contrave
Xenical
Ozempic
N/A
9. Please answer the questions about contraindications for other meds
I have one of the following: (Metformin)
Poor Kidney Function
Congestive Heart Failure
I am over 80 y/o
NA
I have one of the following: (Phentermine)
Hypertension
Anxiety
Depression
Sleep Difficulties
Palpitations
Tachycardia
History of substance abuse
NA
I have one of the following: (Qsymia)
Hypertension
Anxiety
Depression
Sleep Difficulties
Palpitations
Tachycardia
History of substance abuse
Kidney stones
I am on ADHD medication
Glaucoma
NA
I have one of the following: (Contrave)
Hypertension
Anxiety
Depression
Sleep Difficulties
Palpitations
Tachycardia
History of substance abuse
NA
I have one of the following: (Xenical)
GI issues
IBS
My job does not allow breaks for fecal urgency
NA
Not Qualified
Q5
Qualified for Off-Label Use
Q2
Q4 or Q6
Qualified
Tirzepatide Dosing
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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
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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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