💉 Tirzepatide Initial Assessment Template

💷 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