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Clockwork Pharmacy

Date: 05/08/2025

Weight Loss - Mounjaro - Risk Assessment Form

👤 Patient Personal Details

Title *

Mr Miss Ms Mrs Dr

Name *

Surname *

Email *

Mobile *

Gender *

Male Female

Date of Birth *

Patient Address *

GP Name and Address (Optional)

✅ Reason for Inclusion

Patient over 18 years of age with an initial Body Mass Index (BMI) of >30 kg/m² (obese) Patient over 18 years of age with an initial Body Mass Index (BMI) of between 27 kg/m² and 30 kg/m² with at least one weight-related comorbidity such as dysglycaemia (pre-diabetes, or type 2 diabetes mellitus), hypertension, dyslipidaemia, or obstructive sleep apnoea On-going treatment - Treatment with Mounjaro can be continued if the patient has lost at least 5% of their initial body weight after 6 months

📊 Weight Management History

Please list all your current prescription medication including any medication you buy over the counter:

Have you received advice from a weight management counsellor before?

Yes No

Have you tried to manage your weight by altering your diet and increasing physical activity?

Yes No

Has a low-calorie diet failed to manage your weight in the past?

Yes No

Would you object to following a low-calorie diet as part of treatment?

Yes No

📋 Assessment Details (Healthcare Professional Use Only)

Weight (kg)

Height (cm)

Body Mass Index (BMI) kg/m²

Blood Pressure (mmHg)

'Central' Fat Distribution - Waist Circumference (cm)

Co-morbidities Present

Further relevant information (medications, conditions, notes)

📝 Patient Consent

Signature of Patient *

Date

Do you consent to our pharmacy contacting you on other medical services we provide?

Yes No

Our pharmacy offers professional, compassionate care—providing expert advice, timely service, and ongoing support to ensure every patient’s well-being and satisfaction.

Walk in anytime—Walk in for weight loss meds—no wait, no appointment!

Start your weight loss journey with us

Weight Loss - Mounjaro - Risk Assessment Form

👤 Patient Personal Details

✅ Reason for Inclusion

🏥 Medical Assessment

Have you ever been diagnosed with or experienced any of the following conditions?

📊 Weight Management History

❤️ Additional Health Factors

Do you have any of the following conditions?

👩 Women Only

📋 Assessment Details (Healthcare Professional Use Only)

📝 Patient Consent

215-217 Hackney Greater London E9 7HD

Weight Loss Management

Start your weight loss journey with us

Weight Loss - Mounjaro - Risk Assessment Form

👤 Patient Personal Details

✅ Reason for Inclusion

🏥 Medical Assessment

Have you ever been diagnosed with or experienced any of the following conditions?

📊 Weight Management History

❤️ Additional Health Factors

Do you have any of the following conditions?

👩 Women Only

📋 Assessment Details (Healthcare Professional Use Only)

📝 Patient Consent

215-217 Hackney Greater London E9 7HD