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Weight Loss Programme

Gender
Date of Birth
Day
Month
Year

Medical History

Are you currently using any weight loss medication? This includes tablets or injections that we’ve been prescribing for you, or ones you're getting from another provider.
Yes
No
How would you describe your ethnic background? What’s considered a healthy weight can be different depending on your ethnic background. Tell us how you describe yourself so we can ensure you’re getting the right care.
Do you have any of these conditions?
Have you ever had an eating disorder? For example, bulimia oranoerexia. If you think you may have an eating disorder, but have never been diagnosed, please select "yes".
Yes
No
Do you have kidney disease? This might include chronic kidney disease (CKD), polycystic kidneys or kidney failure.
Yes
No
Are you currently pregnant, breastfeeding, or trying to get pregnant?
Yes
No
Unsure
Are there any other significant illnesses or medical conditions that you haven’t mentioned already? This could be a current or past condition.
Yes
No
Are you allergic to any medicines or other substances? For example, peanuts, soya, or other medications (including weight loss medications you’ve previously used).
Yes
No
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Date
Day
Month
Year

How to take your Mounjaro dose

Mounjaro comes in the form of an injectable pen, with pre-filled doses. This means you don’t need to draw up your dose before injecting it. You should take Mounjaro once weekly, at the same time and day. This makes the medication most effective and can reduce side effects by keeping the medication at a steady level.

The Mounjaro ‘KwikPen’ is a single-patient-use pen that contains 4 fixed doses, with 1 dose injected each week. That means 1 pen provides 4 weeks of treatment. Once all 4 doses have been used, you can throw the pen away.

Mounjaro can be injected into the abdomen. It may also be injected into the upper arms but only with help from someone else. Switch your injection site each week to prevent soreness and irritation.


Your used Mounjaro pen can be stored at room temperature, up to 30 degrees Celsius (°C), for no more than 30 days. Keep it away from direct light and in its original packaging. You can also store it in a fridge between 2 and 8°C and if you choose this method, it does not need to be discarded after 30 days.

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