Weight Loss Questionnaire

Please complete the below form and one of our Pharmacists will be in touch within 24 hours during Monday to Friday.

Weight Loss Assessment

Important Information About Weight Loss Treatment

Before completing the assessment, please review the information below about weight loss treatments such as Mounjaro (Tirzepatide) and Wegovy (Semaglutide). These medications can support weight loss when combined with healthy lifestyle changes.

It is important that you understand how these treatments work, their benefits and potential risks before continuing.

Everything You Need To Know About Mounjaro and Wegovy

Please read more information here.

What are Mounjaro and Wegovy, and how do they work?

Mounjaro and Wegovy are 2 different medicines that help with weight loss. Both medicines must be combined with a reduced-calorie diet and increased physical activity for best results.

Mounjaro: A weekly injection that mimics two natural hormones (GIP + GLP1). These hormones reduce appetite, slow down digestion so you feel fuller for longer, and improve blood sugar control.

Wegovy: A weekly injection that mimics one natural hormone (GLP1). This reduces appetite and slows digestion, helping patients to eat less and lose weight.

How much do they cost?

Mounjaro

2.5 mg pen (4 weeks) – £180

5 mg pen (4 weeks) – £200

7.5 mg pen (4 weeks) – £250

10 mg pen (4 weeks) – £280

12.5 mg pen (4 weeks) – £290

15 mg pen (4 weeks) – £310

Refer a friend and you both get £20 off your next Mounjaro pen.

Wegovy

0.25 mg pen (4 weeks) – £120

0.5 mg pen (4 weeks) – £135

1.0 mg pen (4 weeks) – £140

1.7 mg pen (4 weeks) – £180

2.4 mg pen (4 weeks) – £220

How effective are they?

Mounjaro (in SURMOUNT-1 & SURMOUNT-5): After 72 weeks, participants on the highest dose (15 mg) achieved an average weight loss of 20–22%.

Wegovy (in the STEP-1 trial): After 68 weeks, participants on the full dose (2.4 mg) achieved an average weight loss of 16%.

Switching from Mounjaro to Wegovy

If you are currently using Mounjaro but need to switch to Wegovy, please note:

You must not take both medicines at the same time. Leave at least one week after your last Mounjaro injection before starting Wegovy. Your starting Wegovy dose will depend on the current Mounjaro dose you were using. If you experience a lot of side effects when you started Mounjaro then it may be better to switch to a lower dose of Wegovy.

Mounjaro 2.5 mg (£180) → Wegovy 0.25 mg (£120)

Mounjaro 5 mg (£200) → Wegovy 0.5 mg (£135)

Mounjaro 7.5 mg (£250) → Wegovy 0.5 mg (£135)

Mounjaro 10 mg (£280) → Wegovy 1.0 mg (£140)

Mounjaro 12.5 mg (£290) → Wegovy 1.0 mg (£140)

Mounjaro 15 mg (£320) → Wegovy 1.0 mg (£140)

If the switch is tolerated the dose can be increased but if not tolerated can reduce dose or switch back to Mounjaro.

Who can use Mounjaro or Wegovy?

Adults aged 18 and over who are starting treatment with:

A BMI of 30 or above
A BMI of 27 or above and you have a weight-related health condition such as: high blood pressure, high cholesterol, cardiovascular disease, prediabetes, knee or hip osteoarthritis, obstructive sleep apnoea, asthma/chronic obstructive pulmonary disease (COPD), liver disease (nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH)) and polycystic ovary syndrome (PCOS).
Adults who are continuing treatment until BMI is less than 23 then should be discontinued.
People with a South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background will use lower BMI thresholds due to increased risks of being overweight. BMI thresholds for these patients are reduced by 2.5.

How do I use Mounjaro or Wegovy?

Mounjaro is injected under the skin once a week with or without food. You should try to take it at the same time each week.

Each Mounjaro pen has 4 doses and lasts for 4 weeks of treatment, then you’ll need to start a new pen.

What should I do if I miss a dose?

If a dose is missed, it should be administered as soon as possible and within 5 days after the missed dose. If more than 5 days have passed, the missed dose should be skipped, and the next dose should be administered on the regularly scheduled day. In each case, patients can then resume their regular once weekly dosing schedule. If more doses are missed, reducing the starting dose for re-initiation should be considered.

Who should not use weight loss medication?

Pregnant or Breastfeeding
Patients with or history of Gall stones
Patients with or history of pancreatitis
Patients with severe or end stage kidney disease
Patients with severe liver disease
Patient has congestive heart failure New York Heart Association (NYHA) class IV
Patient has obesity secondary to endocrinological condition, eating disorders or to treatment with medicinal products that may cause weight gain.
Patient is taking any of the following medicines:
- Insulin
- Sulphonylureas (e.g. gliclazide)
- a GLP-1 receptor agonist such as Albiglutide (Tanzeum)
- Dulaglutide (Trulicity)
- Exenatide (Byetta)
- Extended-release exenatide (Bydureon)
- Liraglutide (Victoza)
- Lixisenatide (Lyxumia)
- Semaglutide (Ozempic).
- Other medication for weight management (including over the counter or herbal slimming aids)

Possible Side Effects of Mounjaro and Wegovy

Please read more information here.

Upset stomach were the most common side effects, effecting more then 1 in 10 patients.

These include:

Nausea
Vomiting
Diarrhoea
Constipation
Headache
Abdominal pain
Fatigue.

Some other side effects

Common (more then 1/100 to less then 1/10)

Dyspepsia
Gastritis
Gastro-oesophageal reflux disease
Flatulence
Eructation
Abdominal distension
Dizziness
Hypoglycaemia (in patients with diabetes)
Hair loss
Injection site reactions
Cholelithiasis
Diabetic retinopathy (in patients with T2 diabetes). Please refer to the patient information leaflet for more information.

Gall Stones (Cholelithiasis)
Gall stones can occur anyone who experience severe pain in upper right or centre abdomen that may spread to your right shoulder or back, tenderness over your abdomen when it’s touched, nausea, vomiting, fever should be advised to stop taking the medication and return to the pharmacy or contact their GP if they experience any symptoms.

Pancreatitis
Symptoms of acute pancreatitis including vomiting, diarrhoea, indigestion, fever, jaundice, abdominal tenderness/swelling, tachycardia. If pancreatitis is suspected, patient should be advised to stop taking the medication and return to the pharmacy or contact their GP.

Cancer
Some studies show a small increased risk of thyroid cancer and possibly medullary thyroid cancer (protein vs hormone) with use of this class of medication (GLP1 receptor agonists). There is also literature that shows an increased risk of thyroid cancer in patients with pre-existing thyroid disease. Some studies have found no link. The risk of cancer from obesity is higher then using Mounjaro.

Pregnancy
Women of childbearing potential are recommended to use contraception when treated with Mounjaro.

If a women wishes to become pregnant, or pregnancy occurs, Mounjaro should be discontinued.

Mounjaro should be discontinued at least 2 months before a planned pregnancy.

When I stop Mounjaro or Wegovy will I put weight back on?

It is unlikely that any potential weight loss achieved with Mounjaro would be sustained after treatment is stopped, unless changes to diet and lifestyle are maintained. Hence it is important to maintain a healthy lifestyle, reduced calories, increased exercise along with Mounjaro and after it is stopped to maintain weight loss.

Healthy Lifestyle

Please read more information here.

Healthy Lifestyle

You should increase physical activity to 150 mins/week and a decreased daily calorie intake by following:

You should follow a dietary pattern based on the Eatwell Guide, which shows the proportions in which different types of foods are needed to have a well-balanced and healthy diet.

• Eat at least 5 portions of a variety of fruit and vegetables every day
• Base meals on potatoes, bread, rice, pasta or other starchy carbohydrates; choosing wholegrain versions where possible
• Have some dairy or dairy alternatives (such as soya drinks) choosing lower fat and lower sugar options
• Eat some beans, pulses, fish, eggs, meat and other proteins (including 2 portions of fish every week, one of which should be oily)
• Choose unsaturated oils and spreads and eat in small amounts
• Drink 6-8 cups/glasses of fluid a day
• If consuming foods and drinks high in fat, salt or sugar have these less often and in small amounts
• Limit alcohol to 14 units per week spread over at least 3 days. For more information visit https://www.nhs.uk/better-health/lose-weight

How effective is Mounjaro?

When Mounjaro is combined with a reduced calorie diet and increased exercise, a 72 week study SURMOUNT-1 TRIAL resulted in 15-22.5% weight loss depending on the dose.

Treatment Selection

Please let us know which treatment you are interested in so our pharmacist can guide you appropriately.

Which medicine would you like to use?

Mounjaro

Wegovy

Unsure

Basic Health Information

We need a few personal details so our pharmacist can contact you and review your assessment.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

Postcode

Date of Birth

Contact Number

Emergency Contact Name and Contact No

Doctors Surgery Name

Personal Details

Please provide your current height and weight so we can assess whether this treatment may be suitable for you.

Gender:

Male

Female

Prefer not to say

Other

Current Weight

Current Height

Pregnancy & Breastfeeding

These questions help ensure that treatment is safe and appropriate for you.

Are you, or might you, be pregnant?

Yes

Are you breast feeding?

Yes

Are you trying to become pregnant?

Yes

Allergies

This information helps our pharmacist identify any potential reactions to medications.

Do you have any allergies?

Yes

Please provide details of your allergies:

Previous Weight Loss Treatment

Tell us if you have previously used any prescription weight loss injections or treatments.

Have you previously used weight loss injections such as Mounjaro, Wegovy, Saxenda or Ozempic?

Yes

Please specify:

Medical History

Please tell us about any medical conditions that may affect your suitability for treatment.

Have you or any close family member ever been diagnosed with medullary thyroid cancer or Multiple Endocrine Neoplasia syndrome type 2 (MEN2)?

Yes

Are you suffering from, or have you ever been diagnosed with any of the following conditions?

History of Gall Stones

History of Pancreatitis

Hypersensitivity to Mounjaro or any ingredients

Severe or end stage kidney disease

Severe liver disease

Obesity secondary to endocrinological condition

Eating disorder

Taking medication that causes weight gain

Taking medication for diabetes (Insulin, Gliclazide, GLP-1 medicines)

High blood pressure

High cholesterol

Cardiovascular disease

Pre-diabetes or Diabetes

Knee or hip osteoarthritis

Obstructive sleep apnoea

Asthma / COPD

Polycystic ovary syndrome (PCOS)

Other

Current Medications

List any medications or treatments you are currently taking so we can review potential interactions.

Please list ALL medications you are currently taking and the condition they are used for.

Signature & Declaration

By submitting this form, you confirm that the information provided is correct to the best of your knowledge.

Patient Statement:

The information I have provided in this consultation form is, to the best of my knowledge, accurate and complete. I confirm that I have not knowingly withheld any relevant medical information or condition.

I understand that certain medical conditions listed in this consultation form may make me unsuitable for treatment.

I understand that it is my responsibility to inform the practitioner if my medical circumstances change before or during treatment.

I confirm that I have read and understood the information provided about the medicine and possible side effects.

I accept responsibility for any risks associated with the treatment.

I consent for my GP to be informed of my treatment if required.

I confirm that I have read and understood the information above and consent to the pharmacist reviewing my assessment.

Patient Consent

Please review the statement below and confirm that the information you have provided is accurate.

Patient Signature

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