Medication Administration Record
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Week #
*
Current Weight (in pounds)
*
Starting Weight (in pounds)
*
Body Measurements
*
Rows
Unit of Measurement
Measurements
Neck
inches (in)
center miters (cm)
Bust
inches (in)
center miters (cm)
Chest
inches (in)
center miters (cm)
Upper Arm Left
inches (in)
center miters (cm)
Upper Arm Right
inches (in)
center miters (cm)
Waist
inches (in)
center miters (cm)
Stomach
inches (in)
center miters (cm)
Hips
inches (in)
center miters (cm)
Thighs Left
inches (in)
center miters (cm)
Thighs Right
inches (in)
center miters (cm)
Calves Left
inches (in)
center miters (cm)
Calves Right
inches (in)
center miters (cm)
Medication/Supplement Used?
*
Rows
Date of Injection
Day of the Week
Dose
Injection Site
Notes
Semaglutide
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
10 units (0.25 mg)
20 units (0.5 mg)
25 units
40 units (1 mg)
50 units
60 units (1.5 mg)
68 units (1.7 mg)
75 units
80 units (2 mg)
96 units (2.4mg)
100 units (1ml)
Other
Tirzepatide
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
10 units (0.25 mg)
20 units (0.5 mg)
25 units
40 units (1 mg)
50 units
60 units (1.5 mg)
68 units (1.7 mg)
75 units
80 units (2 mg)
96 units (2.4mg)
100 units (1ml)
Other
SlimShot 1
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
10 units (0.25 mg)
20 units (0.5 mg)
25 units
40 units (1 mg)
50 units
60 units (1.5 mg)
68 units (1.7 mg)
75 units
80 units (2 mg)
96 units (2.4mg)
100 units (1ml)
Other
SlimShot 2
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
10 units (0.25 mg)
20 units (0.5 mg)
25 units
40 units (1 mg)
50 units
60 units (1.5 mg)
68 units (1.7 mg)
75 units
80 units (2 mg)
96 units (2.4mg)
100 units (1ml)
Other
Other
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
10 units (0.25 mg)
20 units (0.5 mg)
25 units
40 units (1 mg)
50 units
60 units (1.5 mg)
68 units (1.7 mg)
75 units
80 units (2 mg)
96 units (2.4mg)
100 units (1ml)
Other
Change in appetite?
*
Please Select
No Change
More
Less
None, No Appetite
Change in cravings?
*
Please Select
No Change
More
Less
None. No Cravings.
Change in hunger?
*
Please Select
No Change
More
Less
None. No Hunger.
Energy Level
*
Please Select
No Change
More Energetic
Less Energetic
Fatigue
Change in Sleep Patterns
*
Please Select
No Change
Better
Can’t Sleep
Change in Mood
*
Please Select
No Change
Pleasant
Down
Anxious
Symptoms of Side Effects
*
Nausea
Vomiting
Constipation
Diarrhea
Acid Reflux/Heart Burns
Indigestion
Burping
Bloating
Headache
Dizziness
Stomach/Belly Pain
None of The Above
Other
End of week Notes, Observations, and/or Concerns:
*
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