Weight Wellness Continuing Care Form
Pur Aesthetics and Wellness
Name
*
First Name
Last Name
E-mail
*
example@example.com
Best number to reach you on
*
Format: (000) 000-0000.
Birth Date
*
-
Month
-
Day
Year
Date
What medication are you currently taking?
*
Please Select
Semaglutide
Tirzepatide
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?
*
Nausea
Vomiting
Heartburn
Diarrhea
Constipation
Fatigue
None
Other
If you answered other to the above question, please describe your symptoms.
Do you need assistance managing any of the above side effects?
*
Please Select
Yes
No
Do you need assistance with your injection technique?
*
Please Select
Yes
No
Are you drinking water at least every 2 hours to stay hydrated?
*
Please Select
Yes
No
Do you need support with your nutrition?
*
Please Select
Yes
No
Are you exercising for a minimum of 30 minutes per day, at least 4 days per week?
*
Please Select
Yes
No
Would you like an in-person follow up appointment with Melissa or Emilee?
*
Please Select
Yes
No
Submit
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