Intake Form: Wellness Injection

Tell Us About Yourself
In order to receive your prescription, please answer these questions for our physician:
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1. Personal Health Info
Do you have diabetic ketoacidosis?*
Do you have any allergies or sensitivities to medications, foods, or other substances?*
Current Medications and Supplements:*

1. Personal Health Info
Have you undergone any surgical procedures before? If yes, please provide details.*
Are you seeing a Physician regularly? Is your physician aware that you are taking this medication?*

2. Personal Weight Info
What is your weight loss goal?*
Are you currently on any GLP-1 weight loss medication such as Ozempic, Zepbound, Semaglutide, etc?*
If YES, what is your current dosage per injection?*
Do you have any family members who struggle with weight?*

3. Personal Wellness Info
How do you relate to this statement: It’s hard to remember the details of what i ate*
How to you relate to this statement: Enjoying a good meal is one of my favorite things to do*
How do you relate to this statement: I often find it difficult to unwind or relax*
How do you relate to this statement: Im always looking for restaurants and foods to try*

3. Personal Wellness Info
How do you relate to this statement: I often turn to food to avoid thinking about upsetting things (Why this matters. Eating releases dopamine (the feel-good hormone) in the brain, which explains why some people turn to food when they're upset. This simple action can turn into a habit, leading to compulsive overeating.)*
How do you relate to this statement: Snacking or enjoying a good meal usually puts me in a better mood*
How do you relate to this statement: I often reward myself with food*
What would reaching your goal weight mean for you? (Select all that apply.)*

5. Contact Information
Full Name*

First NameLast Name
Best Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is the best way for the Doctor to reach you if they have additional questions?*
Should be Empty:

Tell Us About Yourself