Medical Questionnaire
Please answer all the questions
Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Date Of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
2. Please answer the following questions honestly in order to determine your qualification for our semaglutide treatment protocol for weight loss. It is important to answer these questions honestly so that your Advanced Nurse Practitioner can accurately prescribe and dose the medication.
*
Yes
No
Back
Next
3. Do you reside in the state of Nevada?
*
Yes
No
Back
Next
4. Are you at least 18 years of age with United States government issued ID?
*
Yes
No
blanks
blank
Back
Next
5. What is your full name as it appears on your Government Issued ID?
Name
*
First Name
Middle Name
Last Name
Back
Next
6. How much do you weigh?
how much do you weigh? (in pounds)
*
Back
Next
7. How tall are you?
how tall are you? (feet and inches)
*
Back
Next
8. Do you have Type I Diabetes Mellitus?
*
Yes
No
Back
Next
9. Do you have Type II Diabetes Mellitus?
*
Yes
No
Back
Next
10. Do you have past medical history for pancreatitis?
*
Yes
No
Back
Next
11. Do you or a family member have a history of thyroid cancer?
*
Yes
No
Back
Next
12. Do you or a family member have a history of multiple endocrine neoplasia type II ?
*
Yes
No
Back
Next
13. Do you have a history of eye problems? Diabetic retinopathy?
*
Yes
No
Back
Next
15. Do you have a history of renal disease or kidney dysfunction?
*
Yes
NO
Back
Next
16. Have you been treated with any of the following medications?
*
Rybelsus
Ozempic
Wygovy
None of the Above
Back
Next
17. Do you have a history of gallbladder disease?
*
Yes
No
Back
Next
18. Are you capable of and willing to perform injections?
*
Yes
No
Back
Next
19. Do you have a history of hypoglycemia?
*
Yes
No
Back
Next
20. Do you have fatty liver or non-alcoholic fatty liver disease?
*
Yes
No
Back
Next
21. Do you have any allergies (food, medicine, or both)?
*
Yes
No
If Yes Please Explain. Place NA if not applicable
Back
Next
22. Do you have any additional medical information that you feel would be helpful for your Advanced Nurse Practitioner to know when reviewing your information and lab results?
*
Yes
No
If Yes please explain. Place NA if not applicable
Back
Next
22. Do you plan on getting pregnant in the next 6 months?
*
Yes
No
N/A
Back
Next
23. Do you have Hypertension (high blood pressure)?
*
Yes
No
Back
Next
24. Do you have dyslipidemia (high blood lipid levels)
*
Yes
No
Back
Next
25. Do you have diagnosed obstructive sleep apnea?
*
Yes
No
Back
Next
26. Do you have cardiovascular disease?
*
Yes
No
Back
Next
27. Do you have problems with blood sugar control?
*
Yes
No
Back
Next
28. Do you have problems losing weight?
*
Yes
No
Back
Next
Submit Quiz
Should be Empty: