HealthRX.com · Printable question sheet
Mounjaro rare serious side effects questions for your prescriber
Use this sheet before or during a visit about tirzepatide (Mounjaro). Fill in your history, list the warning signs you are tracking, and bring your questions about pancreatitis, gallbladder disease, kidney injury, low blood sugar and surgery.
My medicine and history
Write what applies to you. Leave blank if unsure and ask.
Medicine name and formFor example tirzepatide, Mounjaro pen
Prescriber name
Pharmacy name and phone
Family history of medullary thyroid carcinomaYes, no or unsure, and which relative
Past serious allergic reaction to this medicine
Insulin or sulfonylurea medicines I takeName each one
Before the visit
Gather these so the visit covers what matters to you.
- Bring your Mounjaro carton and pen so the prescriber can see the medicine details.
- List every other medicine and supplement you take, including insulin and sulfonylureas.
- Note any planned surgery, dental procedure or scan that needs sedation or anesthesia.
- Write down any stomach pain, nausea, vomiting or diarrhea since your last visit.
- Confirm the phone number to call if you think you have pancreatitis or dehydration.
- Check with your pharmacist which low blood sugar signs to watch for with your other medicines.
- Note any vision changes if you have had diabetic retinopathy.
Warning sign tracker
Record any sign listed here and whether you contacted your care team.
| Date | Sign or symptom | How long it lasted | Contacted care |
|---|---|---|---|
Questions to ask
- Which of these serious side effects are most likely for me given my history?
- What abdominal pain should make me stop the medicine and call you right away?
- What signs of dehydration should prompt a call about my kidneys?
- Should my insulin or sulfonylurea dose be reviewed when I start or change Mounjaro?
- What low blood sugar signs should I watch for, and what should I do if they happen?
- How will I know if a gallbladder problem is developing, and what tests would you order?
- Do I need eye checks if I have diabetic retinopathy?
- What should I tell the surgeon or anesthesia team about Mounjaro before a procedure?
- What thyroid symptoms should I report, and is routine thyroid testing useful for me?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.