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
example@example.com
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
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.
Healthy & Unhealthy Habits
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