Weight Loss Injectables Short Questionnaire

Repeat Prescription Form

Please answer all questions accurately.

Mounjaro

Wegovy

Have you experienced any side effects since your last pen?

Yes

Have you been hospitalized or seen a doctor since your last order?

Yes

Your current weight (kg):

Has this changed since your last order?

Decreased

Same

Increased

Are you using the medication exactly as prescribed?

Yes

Have you been diagnosed with any new medical conditions?

Yes

Have you started any new medications?

Yes

Have you experienced any signs of acute pancreatitis? (Severe abdominal pain, vomiting, low blood pressure, swelling)

Yes

Have you experienced any pain under the ribs on the right side? or yellowing of the skin/eyes?

Yes

Are you pregnant, planning pregnancy, or breastfeeding?

Yes

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Do you require a sharps bin with this order?

Yes

*Please only order if one is absolutely required, save the planet.

I confirm the information I have provided is accurate to the best of my knowledge.

I confirm that I am over 18 years of age.

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