Weight Loss Injections Questionnaire
Please select your preferred Weight Loss Injection
*
Please Select
Compounded Semaglutide
Compounded Trizepatide
Date of Birth
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Month
-
Day
Year
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Name
First Name
Last Name
Address
Street Address
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City
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District of Columbia
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Ohio
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Pennsylvania
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Patient Referral
1 Are you between the ages of 18 and 70?
YES
NO
2 Do you have a history of ileus, tachycardia, orthostatic hypotension, hypoglycemia, pancreatitis or diabetic retinopathy?
YES
NO
3 Have you had gastric bypass or a sleeve in the last 18 months?
Yes
No
4 Have you been diagnosed or treated for disordered eating eating disorders anorexia bulimia abnormal unexplained weight loss?
Yes
No
5 Are you currently being treated for substance abuse or dependency problem?
Yes
No
6 Do you have a personal history of kidney disease liver disease or heart failure?
Yes
No
7 Do you have a history of kidney disease gallstones or gallbladder disease?
Yes
No
8 Do you have a history of gastritis?
Yes
No
9 Do you have a personal or family history of Medullary Thyroid Cancer or Multiple Endocrine Neoplasia Syndrome Type 2 MEN2?
Yes
No
10 Are you currently being treated for any type of cancer?
Yes
No
11 Do you have prediabetes type 1 diabetes or an A1c above 5.7?
Yes
No
12 Do you have a history of intestinal ileus GI diseases such as crohns disease or ulcerative colitis tachycardia orthostatic hypotension unexplained hypoglycemia pancreatitis diabetic retinopathy high cholesterol fatty liver disease high blood pressure or gallstones?
Yes
No
13 If female are you breastfeeding pregnant or planning on getting pregnant in the next two months?
Yes
No
14 Have you previously taken compounded GLP-1 semaglutide or tirzepatide and experienced serious side effects? (such as hypersensitivity reactions - angioedema, anaphylaxis etc.?
Yes
No
15 What are your known allergies? Write NA if no allergies.
16 Are you currently taking any medications?
Yes
No
17 What medications are you currently taking?
Compounded GLP-1 Inhibitor
Insulin
Glipizide
SGLT2
Metformin or
diabetic medication
Others
Not Applicable
18 Do you have suicidal behavior or ideation?
Yes
No
19 What is your weight
20 What is your height
21 What is your BMI (Copy the link below to web browser to calculate BMI)
https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
22 What is your goal weight?
23 Are you willing to make lifestyle modifications including decreased caloric intake and exercise along with your medication?
Yes
No
24 Do you have lab tests?
Yes
No
25 Patient notice and consent. This treatment has Black Box warning. Very rare but potential risk for medullary cancer. Seen in rodent studies, never seen in human trials. In addition to common potential side effects: Nausea, decrease in appetite, stomach pains and discomfort, headache, tiredness, constipation and elevated heart rate. Do you consent to be treated with Comoounded GLP-1 weight loss injections?
Yes
No
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