Weight Wellness Continuing Care Form

Weight Wellness Continuing Care Form

Pur Aesthetics and Wellness
Name*

First NameLast Name
E-mail*
example@example.com
Best number to reach you on*
Birth Date*

MonthDayYear
Date
What medication are you currently taking?*
What is your current dosage (mg/week)?*
What is your height (in)?*
What was your starting weight (lbs)?*
What is your current weight (lbs)?*
Are you experiencing any of the following side effects?*

NauseaVomitingHeartburnDiarrheaConstipationFatigueNoneOther
If you answered other to the above question, please describe your symptoms.
Do you need assistance managing any of the above side effects?*
Do you need assistance with your injection technique?*
Are you drinking water at least every 2 hours to stay hydrated?*
Do you need support with your nutrition?*
Are you exercising for a minimum of 30 minutes per day, at least 4 days per week?*
Would you like an in-person follow up appointment with Melissa or Emilee?*
Should be Empty: