Tirzepatide Initial Assessment Template

Tirzepatide Initial Assessment Template

💉 Tirzepatide Initial Assessment Template

This appears as below:

💷 When would I use this?
This template supports assessment and documentation for NHS-funded tirzepatide prescribing in line with the NHS Funding Variation and Priority Cohorts criteria.
While there is no direct QOF payment, accurate completion ensures:

  • Compliance with national and local eligibility requirements

  • Access to funded treatment for eligible patients

  • Avoidance of prescribing outside scope, reducing clinical and financial risk

📊 High-level overview of the specification requirements
This template supports:

  • Recording patient demographics and baseline measurements for eligibility assessment

  • Documenting comorbidities in line with NHS Priority Cohorts

  • Capturing key considerations such as mental health status, pregnancy status, and medication interactions

  • Confirming wraparound care referral and consent – a requirement for treatment initiation and continuation

  • Documenting obesity medication review prior to prescribing

📌 What do you need to know?

⚖️ Eligibility Criteria
Record:

  • Age ≥18 years

  • BMI ≥40 (or ≥37.5 for South Asian, Chinese, other Asian, Middle Eastern, Black African, African-Caribbean)

  • At least 4 comorbidities from: dyslipidaemia, hypertension, ASCVD, OSA, type 2 diabetes

📏 Personal Information & Measurements

  • Ethnicity (affects BMI threshold)

  • Height (cm)

  • Baseline weight (kg) – mandatory for weight-loss tracking

  • Current weight (kg)

  • BMI (calculated)

🩺 Comorbidities – Dyslipidaemia

  • Tick-box diagnosis

  • Lipid profile: total cholesterol, HDL, triglycerides, LDL, non-HDL, cholesterol/HDL ratio

✅ Confirmation of Eligibility

  • Tick-box to confirm patient meets full criteria

🧠 Mental Health

  • No history / Well-controlled / Not well-controlled

💊 Specific Considerations

  • Gastric emptying delay – check for oral medication interactions

  • Pregnancy/breastfeeding status – confirm not pregnant and not conceiving in next month

  • Contraception education if relevant

📜 Referral Activity

  • Record if weight management services or intensive programmes declined

  • Document any diet replacement programme referrals

🤝 Wraparound Care

  • NHS obesity medication pathway status: started / declined / unsuitable

  • Confirmation of consent

  • Referral to wraparound care pathway

💊 Obesity Medication Review

  • Tick-box to confirm review completed prior to prescribing

💡 Hints and Tips

  • Always record baseline weight – required for percentage weight-loss calculations

  • Double-check ethnicity to ensure correct BMI threshold

  • Record ≥4 comorbidities clearly – patients not meeting this will be ineligible

  • Wraparound care engagement is mandatory – lack of referral or consent will block prescribing

  • Check for medication interactions, especially narrow therapeutic index drugs, when starting or adjusting tirzepatide