Patient Intake Form GLP1 Shots

Patient Intake Form for Semaglutide/Tirzepatide Treatment

Full Name*

Who Referred you to our services: Please Type Name of Company or Name of Person *

Date of Birth*

Date

Gender*

Address*

Phone Number*

Email*

example@example.com

Emergency Contact Name*

Phone Number*

Current Medications*

Medical History- Click all that apply*

Allergies (include medication/food allergies)Are you currently pregnant or breastfeeding?Do you have a history of diabetes or high blood sugar?Have you ever been diagnosed with thyroid cancer or pancreatitis?Are you currently being treated for any chronic conditions?

Allergies include medicationfood allergies- List or Put N/A*

Are you currently being treated for any chronic conditions- List or Put N/A*

What is your current weight and BMI if known?*

Have you used weight loss medications or treatments in the past? Yes or No- If yes please list below:*

Do you currently follow any specific diet or exercise routine?Yes or No*

Do you have a family history of thyroid tumors, including medullary thyroid carcinoma? If yes, please explain:*

Do you have a history of any cardiovascular conditions heart attack stroke high blood pressure? Yes or No if yes please explain:*

Have you ever experienced any gastrointestinal issues such as frequent nausea vomiting or gallbladder problems? Yes or No*

Have you experienced rapid weight loss in the past? Yes or No*

If yes how much and over what period of time*

Are you currently on any GLP1 receptor agonist therapy such as Ozempic, Wegovy Semiglutide or Tirzepitide? Yes or No*

What is your current dose? *

How long have you been on the medication?*

What has been your experience with the medication? *

How much weight have you lost while on the medication? *

Have you experienced any major side effects? Yes or No*

How many times per week do you exercise?*

Do you smoke or use tobacco products? Yes or No*

How often do you consume alcohol?*

Are you willing to make lifestyle changes to support weight loss (e.g., diet, physical activity)? (Yes/No):*

What is your primary goal for starting Semaglutide/Tirzepatide therapy? Weight Loss? Improve Blood Sugar Control? Other:*

What is your target weight?*

Do you have any specific concerns or questions about this treatment?*

Were you referred if so by Who?*

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I acknowledge that I have been informed about the potential benefits and risks of Semaglutide/Tirzepatide treatment, and I consent to undergo this therapy under the guidance of a licensed medical professional.

Signature*

Date*

Date