Patient Medical History Form- Semaglutide and Tirzepatide

General Patient Information

Semaglutide and Tirzepatide Medical Intake
Patient Name*

First NameLast Name
Patient Gender*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Birth Date*

MonthDayYear
Patient Height (in)*
Patient Weight (lbs)*
Patient E-Mail
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Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesOsteoporosisEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid Problems- Medullary thyroid, carcinoma or Endocrine Neoplasia Syndrome Type 2TuberculosisVenereal DiseaseBleeding DisordersLung DiseaseEmphysemaPancreatitisUnstable mental health, depression, eating disordersStrokeHIV/AIDSBlood transfusionHigh ColesterolHormone ImbalanceGall bladder DisorderAutoimmune disorderPleurisyUlcersFrequent Headaches/MigrainesPregnant or BreastfeedingCurrently on Birth control
Other illnesses:
History of Diabetes? If so, what age were you at diagnosis?
Females: Date of Last Menstrual Cycle? Do you have normal cycles?
Family History: Tell us about your families medical history, including age, general health, diseases, overweight, cause of death?
Please list any Operations and Dates of Each
Please list your Current Medications
Healthy & Unhealthy Habits
Please tell us: 1-Your main reason for your decision to lose weight?, 2-Desired weight?, 3-What was your weight one year ago? 4-What is the most you have weighed and when (non pregnant)? 5- How often do you eat out? 6- What foods do you crave, and how often? 7-Please list diets you have followed in the past.
Exercise

Never1-2 days3-4 days5+ days
Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
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General Patient Information

Patient Medical History

Healthy & Unhealthy Habits