Weight Loss - Patient Information Form

1
Full Name* This field is required.
First Name
Last Name
2
What is your age?* This field is required.
3
What is your gender?* This field is required.
Please Select
Please Select
Male
Female
N/A
4
Contact Number* This field is required.
5
Email Address* This field is required.
example@example.com
6
What is your current weight? (lbs.) ** This field is required.
7
What is your height? (cm)* This field is required.
8
Check the conditions that apply to you* This field is required.Please skip if none of these conditions applies to you.
None, I’m perfectly well
Type 2 Diabetes
Cancer
Medullary Thyroid Carcinoma
Liver Disease or Kidney Disease
Hypertension
Seizure disorder (Epilepsy)
Gastroparesis
Acute pancreatitis or acute gallbladder disease
Suicidal behavior or Ideation
Multiple Endocrene Neoplasia Syndrome
Others
9
Are you currently taking any medication?
Yes
No
10
List All Medications You Are Now Taking (Please Include Over-the-counter Vitamins, Herbs, Pain Relievers And Illegal Drugs)
11
Do you have any medication allergies?* This field is required.
Yes
No
Not Sure
12
Have you been diagnosed with obesity or overweight with at least one weight-related condition (e.g., high blood pressure, type 2 diabetes, high cholesterol)? * This field is required.
YESNO
13
What is your primary goal for taking semaglutide?
Blood Sugar control
Weight loss
Both
14
What is your current dietary habit?
Vegetarian
Pescatarian
Vegan
Omnivorius
Others
15
What is your current exercise routine?
None
Moderate ( 3-4 times a week)
Light (1-2 times a week)
Intense ( 5 or more times a week)
16
Have you used semaglutide before?
YESNO
17
If yes, please describe your experience with semaglutide.
Huge
Large
Normal
Small
Ok
Ok
18
Are you aware of the potential side effects of semaglutide?
YESNO
19
Do you understand the importance of regular monitoring and follow-up appointments while using semaglutide?
YESNO
20
Do you have any additional questions or concerns about taking semaglutide?
21
I, {firstname}, have reviewed the information on this medical history form and it is accurate to the best of my knowledge. I understand that this information will be used by the doctor to help determine appropriate and healthful treatment. If there is any change in my medical status, I will inform the doctor. I authorize the insurance company indicated on this form to pay to the doctor all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.* This field is required.Put your signature below.
Clear
22
Thank you for your interest on Semaglutide injections, please be advised that with your current condition we highly recommend you present your laboratory tests and talk to your physician.

If you have your lab test with you and want to connect with our healthcare professionals, send us a message at eyecandyrejuvenations@gmail.com.
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