Quarterly Weight Management Progress Report (3 Month Check-In)

Name:

First Name or Preferred NameLast Name

Date of birth:

Date

Email:

Submission of an email address authorizes this office to communicate medical information by email. While reasonable safeguards are used to protect privacy, patients are advised that email is not a fully secure method of communication and may carry some risk of unauthorized access. By providing an email address, consent is given to receive medical information through this method despite these risks.

Mobile number:

"By leaving a mobile or cell phone number, consent is given to receive SMS messages (msg & data rates may apply; reply STOP to unsubscribe).".Format: (000) 000-0000.

Do you have a different residential/delivery address or phone number since last progress report or visit?

Other

Residential Address (if different from previous):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Shipping/Delivery Address (if different from residential or previous):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medication allergies:

Other

List medication allergies:

Height:

Starting Weight:

Current Weight:

Goal Weight:

Which GLP medication are you currently using (if applicable)?:

When was your last injection (if applicable)?

Is your current GLP medication the one you would like to continue?

If you are requesting a switch in GLP medication, which one(s) are you considering (check all that apply).

If using Wegovy, Ozempic, or semaglutide - what was your last dose (if known)? We are referring to the strength of your medication, not the units being injected.

If using Zepbound, Mounjaro, or tirzepatide - what was your last dose (if known)? We are referring to the strength of your medication, not the units being injected.

If you have used or are using a different GLP (i.e. Retatrutide, Saxenda/liraglutide, Trulicity/dulaglutide, etc) what was your last dose (if known)? We are referring to the strength of your medication, not the units being injected.

Do you have a history of heart attack or stroke?

Do you have peripheral arterial disease?

Have you ever had pancreatitis?

Other

Have you ever been diagnosed with MASH (metabolic dysfunction-associated steatohepatitis)

Other

Have you been diagnosed with or have a history of obstructive sleep apnea?

For patients without sleep apnea: do you want to be tested or retested for sleep apnea?

Other

Have you had any changes in your medical conditions since the last progress report or visit?

Other

If any change(s) in medical conditions, describe/list.

(REQUIRED) List all current medications and dose (if unknown). If you are currently not using any medications, type none.

(REQUIRED) Our office uses Tebra EHR/EMR (electronic health/medical records). Surescripts may pull up your medication history. Do you give us consent to view your medical history/medications through Surescripts?

Have you had any new surgeries since the last visit?

Other

If you have had any new surgeries since your last visit, please describe/list.

Have you or anyone in your family ever had the following?

Do you have any of the following symptoms? (check all that apply)

How do you feel overall? (check all that apply)

Side effects of the injections (if applicable):

Rows	Never	Minimal	Sometimes	Daily	Not applicable
Nausea
Fatigue
Heartburn
Diarrhea
Constipation
Rash
Bloating
Vomiting
Sulfur burps
Insomnia or sleep disturbances
Upset stomach (indigestion)
Stomach/abdominal pain
Dizziness/lightheadedness
Hypoglycemic (low blood sugar) episodes
Feeling jittery or shaky
Weakness
Mood changes (anxiety, irritability, depression)
Vision or speech changes
(If menstruating female) Irregular menstrual cycles

Other side effects (if applicable):

How is the medication helping you? (check all that apply)

Other benefits:

Rows	Not really	I'm trying	Sometimes	All the time	Not applicable
I am eating healthier overall.
I am eating a lot of protein.
I am eating healthy, complex carbs.
I am eating healthy fats.
I can say no (to food and/or extra portions).
I am drinking enough water.
I am eating enough.
I have reduced alcohol intake.
I am eating much less than I normally do.
I am not drinking soda or juice.
I am eating less processed foods.
I am eating a variety of fruits and vegetables.
Other (list below)

Quarterly Progress Report (3 Month Check-In)