Quarterly Progress Report (3 Month Check-In)
Weight Management Medical Associates
Name:
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First Name or Preferred Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
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).".
Do you have a different residential/delivery address or phone number since last progress report or visit?
Yes
No
I don't know.
Other
Residential Address (if different from previous):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Shipping/Delivery Address (if different from residential or previous):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medication allergies:
No known drug allergies.
Yes (list below).
I don't know.
Other
List medication allergies:
Height:
*
Starting Weight:
Current Weight:
*
Goal Weight:
*
Which GLP medication are you currently using (if applicable)?:
N/A (this will be first time with weekly injectable)
Brand Zepbound
Brand Mounjaro
Compounded tirzepatide (additive TBD)
Brand Wegovy injections
Brand Wegovy oral pills
Brand Ozempic
Compounded semaglutide (additive TBD)
Retatrutide
Other
When was your last injection (if applicable)?
*
Is your current GLP medication the one you would like to continue?
Yes
No - I already know which one I would like to use next (list in Other)
No - I'd like recommendations
I don't know
Other
If you are requesting a switch in GLP medication, which one(s) are you considering (check all that apply).
N/A (this will be first time with weekly injectable)
Brand Zepbound
Brand Mounjaro
Brand Wegovy injections
Brand Wegovy oral pills
Brand Ozempic
Compounded semaglutide (additive TBD)
Compounded tirzepatide (additive TBD)
Retatrutide
Other
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.
0.25mg
0.5mg
1mg
1.7mg
2.4mg
Custom
I am unsure
Other
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.
2.5mg
5mg
7.5mg
10mg
12.5mg
15mg
Custom
I am unsure
Other
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?
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Yes
No
I don't know.
Do you have peripheral arterial disease?
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Yes
No
Unsure
I don't know what that means.
Have you ever had pancreatitis?
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Yes
No
I don't know.
Other
Have you ever been diagnosed with MASH (metabolic dysfunction-associated steatohepatitis)
*
Yes
No, I have never been diagnosed with any liver abnormalities.
No, but I have been told my liver enzymes are elevated and/or I have a fatty liver.
I don't know.
Other
Have you been diagnosed with or have a history of obstructive sleep apnea?
*
Yes
No
Unsure
I don't know what that means.
For patients without sleep apnea: do you want to be tested or retested for sleep apnea?
Yes
No
Unsure
Tried in the past but insurance didn't cover it
Tried in the past but it was too expensive
Tried in the past but too nervous about staying overnight in an unfamiliar environment hooked up to sensors
Other
Have you had any changes in your medical conditions since the last progress report or visit?
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No change.
Yes (list below).
I don't know.
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?
*
Yes, I consent and understand that this information allows the doctor to make safer medical recommendations.
No
Have you had any new surgeries since the last visit?
No change.
Yes (list below).
I don't know.
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?
*
Medullary thyroid carcinoma
Endocrine system condition called Multiple Endocrine Neoplasia
None of the above
I don't know.
Do you have any of the following symptoms? (check all that apply)
Lump or swelling in your neck
Hoarseness
Trouble swallowing
Problems breathing
Swelling of your face, lips, throat, or tongue
Upper stomach pain (gallbladder, pancreas)
Menstrual cycle changes
None of the above
Other
How do you feel overall? (check all that apply)
Miserable
Poor
Fair
Good
Better
Great
Amazing
Other
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)
N/A (this will be first time using weekly injectable)
I am not thinking about food as much.
I am eating smaller portions.
I get full faster.
It is helping with weight loss.
Food smells/tastes different.
It has reduced my compulsion about food and eating.
It is reducing my appetite.
It is not helping me.
I have reduced inflammation.
It takes away the background noise of thinking about food
I have fewer cravings.
I don't know.
Other
Other benefits:
Back
Next
Save
Activity (check all that apply):
I'm not doing structured exercise yet.
I like to be outside (walking, biking, hiking).
I am going to the gym.
I exercise several days out of the week.
I am on my treadmill or peloton.
I am working out at home or with videos.
I am trying to change up my exercise routine.
I am doing a lot of outside work (mowing, gardening, planting).
I am chasing my kids/grandkids/great-grandkids all the time.
I am on my feet all day at work.
Other
Dietary habits and behavior modification:
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)
Other dietary habits and behavior modification:
Do you have health insurance that may cover brand name medications that are FDA-approved for weight management (Wegovy or Zepbound)?
Yes
No
I'm not sure
Yes, but I definitely know it does not cover brands Zepbound or Wegovy
My insurance may cover Ozempic or Mounjaro but I do not have type 2 diabetes
My insurance may cover Ozempic or Mounjaro and I do have type 2 diabetes
Other
As the patient, I would like to (check all that apply):
N/A (this will be first time on weekly injectable)
Continue the same medication.
Continue the same dose.
Change medications.
Increase the dose.
Decrease the dose.
I don't know.
Open to recommendations.
Other
Which GLP medication would you like to continue, start, or switch to?
Brand Zepbound auto-injector pens (from my regular pharmacy)
Brand Zepbound vials (from LillyDirect's Self Pay Program)
Brand Wegovy pens
Brand Wegovy oral pills
Brand Ozempic
Brand Mounjaro pens
Comp tirzepatide w/additive TBD (depending on pharmacy)
Comp semaglutide w/additive TBD (depending on pharmacy)
Retatrutide (Striker)
I don't know
Other
Please provide the name and phone number of your regular local or mail-order retail pharmacy for brand medications, generic Zofran, standard B12, etc. (e.g. CVS, Walgreens, Walmart, Express Scripts, Optum RX, Kroger, Tom Thumb, Amazon, Mark Cuban).
*
From your regular retail pharmacy, would you prefer a 30-day supply with refills, or a 90-day supply filled at once? Availability depends on your insurance coverage and pharmacy policies. If you already know your insurance does not cover 90 day medications, check 30 day supply + refills. Check all that apply.
30 day supply + refills
90 day supply filled at the same time
Whatever insurance covers
No preference
Other
If you are not planning to use brand name medications, which compounding pharmacy would you prefer to use? (Select all that apply)
Same pharmacy as last time
Axtell
Casa Pharma
Drug Crafters Frisco
Formulation Compounding Lewisville
Luxe Med Lewisville
Physicians' Choice Infusion (PCI) Bedford
SandsRX Wylie
Stonegate regular processing (free, ETA 5-7 business days)
Stonegate expedited processing (+ $50 fee, ETA 2-3 business days)
Striker Houston
Thesis Plano (formerly known as Texas Star)
I don't know (open to recommendations)
Other
Are there any other medications you would like to start, continue, or request?
No
Standard vitamin B12 shots (cyanocobalamin from my regular pharmacy)
Generic Zofran (ondansetron, from my regular pharmacy)
Lipotropic/MIC/B12 shots (from compounding pharmacy)
Methylcobalamin or hydroxocobalamin shots (from compounding pharmacy)
I don't know.
I am aware Dr. Garza does not prescribe controlled substances like phentermine through the virtual program.
If I am requesting phentermine or any weight loss pill, I will seek a different facility that offers this.
Other
What other questions or concerns would you like to address to Dr. Garza or her staff? Any other feedback or comments are welcome.
OPTIONAL: ATTACH INSURANCE CARDS (FOR MEDICATION), LAB RESULTS, MEDICAL RECORDS
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