Step 1 — Basic Information

2.Height and weight

Height

Body weight

—

BMI calculated automatically

3.What is your primary goal?

I want to start losing weight I want to lose weight after previous unsuccessful attempts I am looking for a long-term weight management plan I want to find out whether I qualify for the program

Step 2 — Health & Body Weight

4.Have you had difficulty managing your weight for more than 6 months?

Yes No

5.Have you previously tried to lose weight?

Yes, through dietary changes Yes, through dietary changes and physical activity Yes, with medication or injectable treatment No

6.Has a doctor ever diagnosed you with any of the following conditions? (you may select multiple)

These conditions are taken into account when assessing eligibility for tirzepatide treatment.

7.Have you previously used any medications to support weight loss?

Yes, tirzepatide (Mounjaro / Zepbound) Yes, semaglutide (Ozempic / Wegovy) Yes, a different medication No

Step 3 — Safety

This step verifies key contraindications to tirzepatide therapy. All questions are required.

8.Are you currently pregnant, breastfeeding, or planning to become pregnant?

Yes No

Pregnancy is a contraindication to tirzepatide use. If pregnancy is planned, discontinuation of the medication in advance is recommended.

9.Have you or any close family member ever been diagnosed with medullary thyroid carcinoma (MTC) or MEN2?

Yes No

A personal or family history of MTC and MEN2 are absolute contraindications to tirzepatide.

10.Have you ever had pancreatitis?

Yes No

11.Do you have any serious gastrointestinal problems?

Yes No

12.Have you ever had a severe allergic reaction to any medication, including injectable treatments?

Yes No

13.Do you have any kidney disease or gallbladder disease?

Yes No

⚠ Possible Contraindication

Based on your answers, a physician will carefully review your case before making an eligibility determination. One or more of your responses indicates that a detailed medical consultation is required.

Your data is confidential and processed in accordance with GDPR.

✓

Questionnaire submitted

Your answers have been submitted for review by a specialist physician, supported by an AI analytical tool. You will receive your eligibility assessment result within 24 hours.

AI Analysis in Progress

Physician Review

Response within 24h

Eligibility Questionnaire

Step 1 — Basic Information

Step 2 — Health & Body Weight

Step 3 — Safety

⚠ Possible Contraindication

Questionnaire submitted