Medical History Form

Full Name

First NameLast Name

What is your age?

What is your gender?

What is your Height blanks . What is your Weight blank

Contact Number

Email Address

example@example.com

Check the conditions that apply to you or any member of your immediate relatives:

Check the symptoms that you' re currently experiencing:

Are you currently taking any medication?

YesNo

Please list all medication you are taking below.

Are you pregnant or possibly pregnant?

Do you have a history of type 1 diabetes

Do you have a personal or family history of medullary thyroid carcinoma or with Multiple Endocrine Neoplasia syndrome type 2?

Do you have Severe gastrointestinal dysmotility, including gastroparesis?

Do you have a History of pancreatitis (does not pertain to patients for whom the cause of pancreatitis is known and no longer presents a risk)

Do you have a history of suicidal attempts or active ideation (unless a mental health consultation supports benefits of semaglutide in a patient with a history of suicide attempts or recent suicidal ideation)

Are you taking another medication FDA-approved for weight loss?

How often do you consume alcohol?

By signings I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I've experienced. I understand that if anyn changes occur in my health or medical history I will report it to the office.

Possible Contraindications or Side Effects

Nausea, vomiting, constipation, diarrhea, heart burn, headache , fatigue, allergic reaction, abdominal pain, hypoglycemia, bloating, gastroenteritis, gas, gerd, and gastroparesis.

I agree to get medical care immediately for any signs of allergic reaction or anaphylaxis and to keep my doctor aware of any side effects I may experience so that the dose may be adjusted accordingly.

I have read ad understand the above medical questionaire. I acknoledge that all answers have been recorded truthfully and i will not hold any staff member responsible for any errors or omissions I have made in completing this form.

Signature

Medical History Form

A Fabulous You by Melissa