GLP-1 Patient Intake Form
OptimalMD
What is your name?
*
First Name
Last Name
What is your gender?
*
Please Select
Male
Female
What is your age?
*
What is your height (inches)?
*
How much do you weigh (lbs)?
*
Do you have any of the following conditions? (select all that apply)
*
High Cholesterol
Fatty Liver Disease
High Blood Pressure
Pre-Diabetes/Type 2 Diabetes/HbA1c 5.7 or higher
None of the above
Other
Do you have any of the following medical conditions? (select all that apply)
*
Medullary Thyroid Cancer (MTC) or family history of MTC or Multiple Endocrine Neoplasia Type 2 or any cancer
Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)
Serious Allergic reaction to Semaglutide or Tirzepitide or compounded components
Active Cancer
Active Drug or Alcohol Misuse
Eating Disorders
Bipolar Disorder
Schizophrenia
Pancreatitis
Diabetes Mellitus Type 1
Any Liver or Kidney Disease
Active Gallbladder Disease
Chronic or persistent Hypoglycemia with ranges < 60 mg/dl
Pregnant or planning to become pregnant in next 2 months
None of the above
What are your weight loss goals?
*
Please Select
Lose 1-20lbs for good
Lose 21-50lbs for good
Lose over 50lbs for good
Maintain my healthy weight
None of the Above
Other
What weight loss initiatives have you tried in the past? (select all that apply)
*
Exercise
Dieting
Weight-Loss Supplements
Intermittent Fasting
Other GLP-1's
Other
Date of Birth
*
-
Month
-
Day
Year
Phone Number:
*
Format: (000) 000-0000.
Do you require translation services?
*
Yes
No
What is your preferred language?
What GLP-1 are you most interested in?
*
Please Select
Compounded Semaglutide
Compounded Tirzepatide
Rybelsus®
Mounjaro®
Ozempic®
Trulicity®
I am not sure and would like to discuss with a Healthcare Provider.
Please upload a government issued form of ID (Driver's License, Passport, etc). Please be sure that your full name and photo are easily visible.
*
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