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BMI & Medical Assessment Questionnaire

BMI & Medical Assessment

Answer a few quick questions to see if you're eligible for Mounjaro.

BMI
Weight Assessment
Your Health
Medical Conditions
Medication
Agreement

BMI Calculator

Measurement System for BMI: Metric Imperial

Your Height (cm)

Your Weight (kg)

Your Height

Feet:

Inches:

Your Weight (lbs)

BMI: --

Weight Assessment

BMI Completed. Please choose your measurement system and then enter your details.

Measurement System: Metric (Height in cm, Weight in kg) Imperial (Height in ft/in, Weight in lbs)

Height (cm):

Weight (kg):

Height - Feet:

Height - Inches:

Weight (lbs):

Your Health

Have you been diagnosed with any conditions such as:

Pre-diabetes
Type 2 diabetes
Hypertension
Heart disease
High cholesterol
Obstructive sleep apnoea

Yes No

Are you between the ages of 18-75? Yes No

Are you pregnant, planning to become pregnant, or breastfeeding? Yes No

Do you have any known allergies or hypersensitivity to GLP-1 agonists? Yes No

Have you ever been diagnosed with an eating disorder (e.g., Anorexia or Bulimia)? Yes No

Medical Conditions

Do you have any other medical conditions? Yes No

Do you have any of the following conditions?

Liver impairment
Kidney impairment
Chronic malabsorption syndrome
Gallstones or inflamed gallbladder
Inflammatory bowel disease (IBD)
Heart failure
Diabetic gastroparesis
Diabetic retinopathy
History of pancreatitis
Severe depression or suicidal thoughts

Yes No

Do you have a personal or family history of thyroid cancers or MEN 2? Yes No

Medication

Are you taking any of the following medications?

Insulin
Sulfonylureas (e.g., gliclazide)
Warfarin or other anti-coagulants
Other weight management products
Other GLP-1 agonists

Yes No

Are you taking levothyroxine or liothyronine for an underactive thyroid? Yes No

Is this the first time you will be using these injectable weight loss treatments? Yes No

Which of the injectable weight loss treatments have you used? (Select all that apply) Saxenda Wegovy Mounjaro Ozempic None of the above

When did you last use an injectable weight loss treatment? Within the last 4 weeks Between 4-8 weeks ago More than 8 weeks ago

Was your previous weight loss pen purchased from us? Yes No

Agreement

Do you understand that this medication must only be combined with a reduced‑calorie diet and increased physical activity? Yes

Do you understand that when starting treatment, you may lose body fluid or become dehydrated? Yes

Do you understand that other weight-loss medications should not be used alongside injectable weight loss medications? Yes

Contact Information

Name:

Email:

Phone Number:

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Weight Loss

Vitamin Injections

IV Therapy

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