Semaglutide Patient Intake Form

1
Hi there! Let's Get Started With Your First & Last Name* This field is required.
First Name
Last Name
2
Could you please provide your email address?* This field is required.
example@example.com
3
What is the best contact number to reach you?* This field is required.
Please enter a valid phone number.
4
Where should we ship your order? Please provide your address.* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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5
When is your date of birth?* This field is required.
Date
Month
Day
Year
6
Do you have any medical diagnosis or condition we should be aware of?* This field is required.Please provide any relevant details to assist us in understanding your health background.
YESNO
7
Can you please list all of your current medical diagnosis?* This field is required.
8
Have you ever been diagnosed with or hospitalized for pancreatitis?* This field is required.If yes, we may need to explore alternative options. (Your safety is our priority, and we want to ensure the best course of action for you.)
YESNO
9
Are you currently taking any medications?* This field is required.
YESNO
10
Which medications do you take, and for what?* This field is required.Please list them, including any birth control medications you may be using. (This helps us understand any potential interactions or considerations for your specific situation.)
11
Do you currently take insulin for diabetes management? * This field is required.Knowing your current diabetes management plan assists us in tailoring our approach to your needs.
YESNO
12
Do you have any known medication allergies?* This field is required.Please list any allergies to ensure your safety during the course of treatment.
13
Does your family have a history of thyroid cancer? If yes, please specify the type, if known.* This field is required.(Understanding your family medical history assists us in assessing any potential risk factors.)
14
How would you describe your current activity level?* This field is required.This helps us gauge your physical activity and tailor recommendations accordingly.
Minimally Active
Moderately Active
Very Active
15
Have you been diagnosed with type 1 diabetes?* This field is required.This information is crucial in determining eligibility for the specific program.
YESNO
16
Are you currently taking any medication for type 2 diabetes such as insulin or oral medication?* This field is required.Knowing your current medication regimen allows us to assess suitability for the program.
YESNO
17
Is there a family history of multiple endocrine neoplasia or thyroid cancer? * This field is required.If yes, please specify the type. Family medical history provides valuable insights into potential hereditary factors.
YESNO
18
What is your current weight & height?
19
What is your goal weight?* This field is required.Having a goal weight helps us establish a target and track your progress effectively.
Enter Your Ideal Weight (In Pounds)
20
How committed are you to achieving your weight loss goals?* This field is required.1-10 (10 Being VERY Committed)
Should be Empty: