Weight Loss Program Intake Form

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

example@example.com

Phone Number*

Area CodePhone Number

Gender

BMI Calculatior

How did you hear about this program?

Appointment

Are you allergic to any of the following

GLP-1 Receptor AgonistsSodium PhospateAdhesive/LatexNone of the above

Have you every been diagnosed with any of the following:

Women Only: Are you currently

Are you currently taking. blood thinners (i.e. Asprin/Warfarin), Bexarotene, Gatifloxacin or any Diabetes Medication (i.e. Insulin or sulfonylureas?):

YesNo

Have you ever taken a GLP-1 Medication

YesNo

If yes, what is your current dose?

What medications, supplements and over the counter items do you take regularly or are currently prescribed:*

Any past surgeries and hospitalizations*

Do you exercise regularly? Please detail.

You have problems falling or staying asleep?

How many hours do you sleep?

Do you wake up refreshed?

How is your energy?

Does your energy level affect your daily activities?

How would describe your mood, generally:

Does your mood affect your life or daily activities?

How would you describe your stress level?

How do you manage stress?

What methods or interventions have you tried in the past to lose weight?

Do you drink

YesNo

If yes, how many per week?

Do you smoke tobacco?

Do you use Recreational Drugs

YesNo

How is your appetite?

How many meals per day do you eat?

How much fluids do you normally drink? Please approximate in ounces.

Health History*

	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Unexplained weight loss or gain
Change in appetite
Depressive symptoms
Anxiety
Mood swings
Nervousness
Addictive dependency
Disordered Eating Pattern/Tendency
Tension
Lack of mental focus
Thyroid problems
Diabetes
Blood sugar irregularities
Excessive thirst or hunger
Sugar cravings
Abnormal hair growth
Excessive perspiration
Feeling excessively hot or cold
Headache
Lightheadednes
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Short of breath
Heartburn
Abdominal discomfort after eating
Nausea
Abdominal bloating
Blelching/gas
Constipation
Diarrhea
Daily bowel movements
Pancreatits
Elevated Blood Lipase Levels
Multiple Endocrine Neoplasia Syndrom Type 2
Meduallary Thyroid Carcinoma

I have read the following documents (are in the pdf version of this intake), fully understand them and agree to their terms (please sign with your cursor below). Documents: Rules & Responsibilities, Acknowledgement and Consent to Privacy Practices and Consent to Limited Treatment.*

I consent to taking a GLP-1 medication (Tirzepatide or Semigludtide) injections as prescribed by my health care provider. Tirzepatide or Semiglutide is a glucose-dependent insuliotropic polypeptide (GIP) receptor and GLP-1 receptor agonist for dieabetes management, with off-label usage for chronic weight managment. I have been informed of the correct administering method and dosage. I will not take this medication if I have a history of the following:

Pregnant of planning to conceive while using this medication
Personal or family history of Medullary Thyroid Carcinaoma or Multipole Endorice Neoplasia Syndrome Type 2 (MEN2)
Pancreatitis, kidney failure/disease, liver failure/disease, digestive issues, or gastroparesis.
Are allergic to Tirzepatide or any GLP-1 agonist medications or you have other undisclosed allergies.
You are diabetic, have retinopathy or take medication to lower blood sugar without consulting your endocrinologist.

Common Side Effects: nausea, diarrhea, decreased appetite, vomitting, constipation, abdominal pain, and indigestion.

Severe Side Effects: Contact your medical professional immediately if you experience the following:

Severe Stomach pain or changes
Eye and vision changes, including blurry vision
Symptoms of hypoglycaemia (dizziness, headaches, increased hunger, raised heart rate, sweating, anziety, irritability, and confusion)
Kidney problems including decreased urination, swilling inthe ankles or feet, shortness of breath and increased tirdness.
Gallbladder pain or changes, including sympotms of chalky stool, upper addominal pain, nausea, vomitting, bloating, and heartburn.
Signs of thyroid tumor, with a lump or swelling in the neck, toruble swallowing, voice,hoarseness or shortness of breath.

STOP THIS MEDICATION AND SEEK IMMEDIATE MEDICAL ATTENTION if you experience the following:

Pancreatitis, with severe upper abdmonial pain that radiaties to the back, which may be accompained by vomitting.
Serious allergic reaction, with rash, itching, sweilling of the face, tongue, or throat, and trouble breathing.

Possible Drug Interactions: anti-diabetic agents can lead to increased risk of hypoglycemia. (Gatifloxacin, Insulin, and Sulfonylureas). Inform your provider of any medications that may lower blood sugar. Do NOT combine with another GLP-1 agonist medicine. Bexarotene increases the risk of pancreatitis and should not be taken along Tirzepatde.

Warnings: Tirzepatide may cause thyroid tumors, as well as the following serious side effects: pancreatitis, hypoglycemia, kidney problems, severe stomach pain, changes in vision, gallbladder pain, as well as allergic reactions. If you take birth control pills, they may not work as effectively while taking GLP-1's.

I acknowlege that Tirzepatiede, Semiglutide, of any GLP-1 is one part of a comprehenseive lifestyle approach that includes a healthy diest, exercise, and regular follow up visits to monitor and adjust dosages as needed. I agree to fill out the "Check in Survey" every Monday during my course of treatment.

By signing below, I confirm that I have been fully informed of the potential risks, benefits, and complications of taking this medication and I voluntarily agree to taking this medication. I have had the opportunity to ask questions, and all my concerns have been addressed to my satisfaction. I realease, Her Wellness, LLC from any liablity or claims arrising from this treatment.

Signature*

Peak Wellness MD

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