Are you male or female?

Male

Female

Enter your date of birth

Are you between the ages of 18 and 74?

Yes

No

How would you like to enter your height?

cm

feet/inches

How would you like to enter your weight?

kg

stones/pounds

Calculated BMI

Do you suffer from prediabetes, diabetes, heart disease, high blood pressure, high cholesterol or obstructive sleep apnoea?

Yes

No

If you have type 2 diabetes, are you on any injections or tablets other than metformin?

Yes

No

Have you experienced an allergic reaction to Mounjaro, Wegovy, Semaglutide, Saxenda, or Liraglutide?

Yes

No

Have you ever suffered with an eating disorder?

Yes

No

Have you been diagnosed with depression or another mental health condition?

Yes

No

Have you had or do you have the following:
Acromegaly or any growth hormone problem
Chronic Malabsorption Syndrome
Cushing’s Syndrome
Gallbladder, Bile duct or Pancreas disease
Gastric surgery (bariatric surgery)
Heart Failure
Hypoglycaemia
Kidney Disease
Liver Disease
Pancreatitis
Severe gastrointestinal disease (e.g. inflammatory bowel disease, ulcerative colitis, Crohn's disease)
Type 1 Diabetes

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Do you or any family member have a history of thyroid cancer or MEN2?

Yes

No

Are you taking any of the following medications?
Amiodarone
Carbamazepine
Ciclosporin
Clozapine
Digoxin
Fenfluramine
Lithium
Oral Methotrexate
Phenobarbital
Phenytoin
Somatrogon
Tacrolimus
Theophylline
Warfarin

Yes

No

Are you taking steroids or medication to treat your thyroid?

Yes

No

Have you taken injectable weight loss medication in the last 4 weeks?

Yes

No

Do you understand that you will be asked to provide evidence of a prescription with an alternative provider if the following applies to you:
This is your first order with Nubody Clinic and you do not order the starter dose
Your last order with Nubody Clinic was more than 8 weeks ago and you wish to order a higher strength
For guidance on selecting the correct dose,

Yes

No

Do you understand that GLP-1 injectable weight-loss medication Mounjaro may reduce the effectiveness of oral contraceptives and that you must use additional non-oral contraception methods (e.g. condoms) during your treatment?

Yes

No

Do you understand that this medication should not be used by men or women that are either trying to conceive or are within two months of starting to try for a child?

Yes

No

Do you understand that there may be an increased risk of pancreatitis, gall bladder problems and gall stones with this medication, and that if you experience any abdominal pain whilst using this medication you should seek medical advice?

Yes

No

Do you understand that injectable weight loss medications should not be used with other weight loss medications?

Yes

No

Do you understand if you develop any lumps in the neck or hoarse voice whilst taking this medication, you should stop the medication and speak to your doctor?

Yes

No

Both weight loss and injectable weight loss treatment has been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental health issues), do you understand you should stop treatment and speak to your doctor?

Yes

No

Both weight loss and injectable weight loss treatment has been associated with a lowering of mood. If you are experiencing this (depression, thoughts of self harm or other mental health issues), do you understand you should stop treatment and speak to your doctor?
You will read the patient information leaflet supplied with your medication.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment.
The treatment is solely for your own use.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

No

I confirm that the information provided is accurate.

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