Weight Loss Injections Questionnaire

Please select your preferred Weight Loss Injection

Date of Birth

MonthDayYear

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState

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?

2 Do you have a history of ileus, tachycardia, orthostatic hypotension, hypoglycemia, pancreatitis or diabetic retinopathy?

3 Have you had gastric bypass or a sleeve in the last 18 months?

4 Have you been diagnosed or treated for disordered eating eating disorders anorexia bulimia abnormal unexplained weight loss?

5 Are you currently being treated for substance abuse or dependency problem?

6 Do you have a personal history of kidney disease liver disease or heart failure?

7 Do you have a history of kidney disease gallstones or gallbladder disease?

8 Do you have a history of gastritis?

9 Do you have a personal or family history of Medullary Thyroid Cancer or Multiple Endocrine Neoplasia Syndrome Type 2 MEN2?

10 Are you currently being treated for any type of cancer?

11 Do you have prediabetes type 1 diabetes or an A1c above 5.7?

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?

13 If female are you breastfeeding pregnant or planning on getting pregnant in the next two months?

14 Have you previously taken compounded GLP-1 semaglutide or tirzepatide and experienced serious side effects? (such as hypersensitivity reactions - angioedema, anaphylaxis etc.?

15 What are your known allergies? Write NA if no allergies.

16 Are you currently taking any medications?

17 What medications are you currently taking?

18 Do you have suicidal behavior or ideation?

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?

24 Do you have lab tests?

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?