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Patient Consultation & Medical History
Full Name*:
Date of Birth*:
Are you on Mounjaro?*:
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Weight (kg)*:
Height (cm)*:
Calculated BMI:
Do you have diabetes?*
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Yes
No
Are you pregnant/breastfeeding?*
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No
Yes
Do you have any of the following conditions?
Thyroid cancer
Pancreatitis
Kidney/Liver disease
Eating disorder
None
Current medications:
Which strength of Mounjaro?*
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2.5mg
5mg
7.5mg
10mg
12.5mg
15mg
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Postcode*:
Mobile Number (+44)*:
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