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Follow Up Consultation - Weight Loss Progress Form
Please use this form to request your next dose. A doctor will review your answers and issue your prescription. If we need to speak with you or see you in person first, we’ll let you know and a doctor will be in touch.
Your Name
*
First
Last
Date of birth
*
DD
/
MM
/
YYYY
Best Contact Number
Email
Current Weight (st/lbs or kg)
*
Please select your current dose
*
Mounjaro 2.5mg
Mounjaro 5mg
Mounjaro 7.5mg
Mounjaro 10mg
Mounjaro 12.5mg
Mounjaro 15mg
Wegovy 0.25mg
Wegovy 0.5mg
Wegovy 1mg
Wegovy 1.7mg
Wegovy 2.4mg
Are you experiencing any side effects on your current dose?
*
Yes (explain in box below)
No
More explanatory information
Are you continuing to lose weight on your current dose?
*
Yes – please prescribe me the same again
No – I think I need to increase my dose
No – I would like to decrease my dose(explain in box below)
More explanatory information
Are you continuing to address a healthy lifestyle in the form of regular exercise and optimal nutrition?
*
Yes, I am really trying and manage to achieve this 80% of the time.
No, I am really struggling with this aspect and would like some support.
I understand that I must seek in person medical help if I am feeling unwell on my weight loss medication
*
Understand
I understand that weight loss medication can reduce the effectiveness of hormonal contraception and I am taking extra non hormonal precautions.
*
Understand
Not Applicable
I understand that weight loss medication may affect my HRT and I have spoken to my doctor about this.
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Understand
Not Applicable
I understand that I must not try for a baby or conceive while on weight loss medication and for at least 2 months after stopping weight loss medication.
*
Understand
Not Applicable
