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2
Medical Screening Questions

Please answer all questions honestly. This information is crucial for your safety.

Do you currently have a diabetes diagnosis?

Have you previously used GLP-1 medications?

Do you have a history of pancreatitis?

Do you have a family history of thyroid cancer?

Are you currently pregnant or breastfeeding?

Do you have a history of eating disorders?

3
Information Acknowledgment

About Mounjaro Injection

Mounjaro (tirzepatide) is a prescription medication used for weight management in adults with obesity or overweight with weight-related medical problems. It works by mimicking hormones that regulate blood sugar and slow gastric emptying, leading to reduced appetite and food intake.

Common Side Effects

  • Nausea and vomiting
  • Diarrhea or constipation
  • Decreased appetite
  • Abdominal pain
  • Fatigue
  • Injection site reactions

Serious Risk Warnings

  • Thyroid tumors, including cancer
  • Pancreatitis (inflammation of the pancreas)
  • Severe allergic reactions
  • Kidney problems
  • Severe low blood sugar
  • Gallbladder problems

Expected Benefits

  • Significant weight loss (average 15-20% of body weight)
  • Improved blood sugar control
  • Reduced appetite and food cravings
  • Potential cardiovascular benefits
  • Improved quality of life

Individual results may vary. Benefits are typically seen with consistent use alongside a healthy diet and exercise program.

Emergency Warning Signs

  • Severe abdominal pain that won't go away
  • Severe nausea and vomiting
  • Signs of allergic reaction (rash, difficulty breathing, swelling)
  • Signs of low blood sugar (shakiness, sweating, confusion)
  • Severe dehydration
  • Unusual lumps or swelling in the neck

4
Responsibility Declaration & Signature

Important Declaration

By proceeding with this treatment, I acknowledge that I have read, understood, and accept full responsibility for my treatment with Mounjaro injection. I understand the risks, benefits, and potential side effects. I commit to contacting my GP or seeking emergency medical care if I experience any adverse effects or concerning symptoms.

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