Semaglutide Safety Assessment Form

1

Be Healthy. Be Happy.BE YOU!

2

Name

First Name

Last Name

3

Date of Birth

4

Sex assigned at birth?

5

Weight & Height

Weight

Height

6

Phone Number

7

Email Address

8

Where do you reside?

Nevada

California

Other

10

When was the first date of your last menstrual period?

Date

11

Are you currently taking any medication?

Yes

No

12

Please list them.

13

Do you have any medication allergies?

Yes

No

Not Sure

14

Please list them.

16

Do you use any kind of tobacco or have you ever used them?

17

What kind of tobacco products? How long have you used/been using them?

18

Do you use any kind of illegal drugs or have you ever used them?

19

What kind of drugs? How long have you used/been using them?

20

Thank you for taking the time to fill out our assessment.

We will be in contact within 48 business hours.

In the meantime, feel free to browse our site and learn more.