Do you have a Body Mass Index (BMI) of 30 or greater?
Do you have a BMI of 27 or greater with one or more weight-related health conditions (e.g., type 2 diabetes, hypertension, dyslipidemia)?
Are you currently taking any medications?
If yes, please list your current medications:
Have you ever taken any weight-loss medications in the past?
If yes, please list:
Do you have any history of pancreatitis or pancreatic disease?
Do you have a family history of thyroid cancer or medullary thyroid carcinoma?
Do you have multiple endocrine neoplasia syndrome type 2 (MEN2)?
Do you have any history of kidney or liver disease?
Do you currently experience gastrointestinal issues such as severe nausea, vomiting, or bloating?
How often do you exercise each week?
Do you follow a particular diet?
If yes, please describe:
Do you currently smoke or use tobacco products?
Do you drink alcohol?
If yes, how often?
Have you tried to lose weight through diet and exercise without significant success?
What is your primary reason for wanting to lose weight?
What is your weight loss goal (in kg or lbs)?
Are you currently pregnant, breastfeeding, or planning to become pregnant?
Do you have any other medical conditions not listed above that could affect your ability to lose weight or take Wegovy?
If yes, please specify:
Based on your responses, the healthcare provider will determine if you meet the eligibility criteria for Wegovy as part of your weight management plan.
Eligible for Wegovy?
Next Steps
