Clinic / Pharmacy Assessment

GLP-1 (Mounjaro) Patient Evaluation

Use this intake form to document baseline metrics, screening flags, and counseling steps.

Step 1 of 5 — Patient Information 20%
Step 01

Patient Basic Information

Patient profile
kg ÷ m²

BMI is calculated automatically when you enter weight and height above.

Step 02

Medical Background

Type 2 Diabetes

Existing conditions

Previous weight loss attempts

Step 03

Eligibility Screening

Physician review if flagged

Current BMI category

Medical history flags

Select any that apply. Flagged items require physician review before initiation.

If any history items are flagged, refer to a physician before initiating Mounjaro therapy. This form supports screening and documentation only.
Step 04

Patient Goals

Primary treatment goal

Step 05 — Final

Counseling Checklist

Pharmacist use

Confirm items covered during counseling

This form supports documentation and routing only. Final eligibility and prescribing decisions must be handled by an authorized clinician.

Submissions are sent to your store email (same as Shopify's default contact form). This form does not store medical data independently.