Weight Loss Consultation

Weight Loss Initial Consultation

During this initial consultation,our healthcare provider will review your overall health, evaluate any potential underlying conditions, and recommend an appropriate weight loss plan tailored to your needs.

This may include diet, exercise, and possible medication options to help you achieve your goals in a safe and sustainable manner.
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemale
Date of Birth*

MonthDayYear
Age
years
Height*
Foot & Inches
Weight*
Lbs
Whats the activity level at your job?

None(seated only)Moderate (light activity such as walking)High (heavy labor, very active)
Do you follow a regular working schedule, do you work days, afternoon or nights?
Please list the physical activities that you participate in outside of the gym and outside of work:
If you have any diagnosed health problems list the condition(s).
If you are on any medications, please list them.
What additional therapies are being undertaken for the given health problem(s)?
"If you have any allergies to any medication, please include whether it is to Semaglutide or Tirzepatide?
What additional therapies are being undertaken for the given injury?
Are you experiencing any stresses or motivational problems?

YesNo
Has anyone of your immediate family developed heart disease before the age of 60?

YesNo
Do you sleep at least 7 hours a day?

YesNo
Do you suffer from diabetes, thyroid disease or thyroid cancer, high blood pressure?

YesNo
Please list:
Are you a current cigarette smoker?

YesNo
Your current diet could be best characterized as:

Low-fatLow-carbHigh-proteinVegetarian/VeganNo special diet
What following goals does best fit in with your goals?

Improved healthImproved enduranceIncreased strengthIncreased muscle massFat loss
What is your goal with your weight loss journey?

TImeline for achieving your goal.

	5 WKS	6 WKS	10 WKS	1 YEAR
NOW

How often are you willing to train a week to reach your goal?
Please rate your motivational level to do what it takes for reach your goal.

12345678910
Are you currently excersising regulary (at least 3x per week)?

YesNo
Food triggers (check all that apply):

stressBoredomAngerInsomniaSeeking rewardPartiesEating outOther:
Have you tried any weight loss medication before?
If you have tried any treatment, you can mention one of the following?

AdipexDietDiureticsOver the counter medicationsLaxativesBontrilAlliSemaglutideTirzapideTopamaxContrave
Food cravings:

SugarSaltyStarchesFast foodHigh fatLarge portions
What are your expectations on your weight loss journey?
Which treatment are you interested in?

SemaglutideTirzepatideAlli / XenicalLipo MinoL-carnitineOther
Tirzepatide is a medication that belongs to a class known as agonists of the glucose-dependent insulinotropic peptide (GIP) receptors and glucagon-like peptide 1 (GLP-1) receptors. These two compounds are hormones that play a key role in regulating blood sugar levels. Tirzepatide works by stimulating both receptors, which helps improve blood glucose control, in addition to promoting weight loss by reducing appetite and improving insulin sensitivity.

Semaglutide: is a medication that belongs to a class known as GLP-1 receptor agonists. GLP-1 (glucagon-like peptide 1) is a hormone that plays a key role in regulating blood sugar levels. Semaglutide works by stimulating the GLP-1 receptor, which helps improve blood glucose control, promotes insulin release when glucose levels are high, reduces glucagon (a hormone that increases blood sugar), and slows gastric emptying. In addition to improving blood sugar control, it also helps with weight loss by reducing appetite.

Lipo Mino: is a combination of injectable lipotropic and vitamin-based supplements commonly used to aid in weight loss and fat metabolism. The goal of Lipo Mino is to promote fat loss, improve metabolism, and support overall weight management efforts.

L-Carnitine: L-Carnitine is a naturally occurring compound that helps the body convert fat into energy. It's often used as a supplement to support weight loss, improve exercise performance, and enhance fat burning.

MICC: MICC stands for Methionine, Inositol, Choline, and Cytomel (sometimes combined with other nutrients). This combination is used in weight loss treatments because each component plays a role in supporting fat metabolism and liver health:Methionine: An amino acid that helps the liver process and eliminate fat.
Side Effects

Both Tirzepatide and Semaglutide can cause some common side effects, though they are generally mild. These may include nausea, vomiting, diarrhea, constipation, abdominal pain, and decreased appetite. Other possible side effects include indigestion and headaches. While these side effects typically improve as the body adjusts to the medication, it's important to contact your healthcare provider if you experience severe or persistent symptoms.

L-carnitine is a supplement commonly used for fat burning and increased energy. The most common side effects include:

Stomach discomfort: Nausea, diarrhea, or abdominal cramps.
Body odor: It may cause a fishy smell in sweat and breath.
Muscle pain: In some cases, muscle aches or cramps are reported.
Insomnia: Increased energy, which can interfere with sleep if taken late in the day.
Increased appetite: Some people experience an increase in appetite.

Mic (Micronutrients):For micronutrient supplements (Mic), side effects usually depend on the doses, but they tend to be mild. Some effects include:Gastrointestinal issues: Such as nausea or stomach discomfort.
Allergic reactions: In rare cases, skin rashes or itching may occur.
Deficiency of other nutrients: If taken excessively, they may interfere with the absorption of other important nutrients.

Who should not use Tirzepatide or Semaglutide?

Tirzepatide and semaglutide should not be used by individuals who:
- Have a history of severe allergic reactions to any of the components of these medications.
- Are pregnant or breastfeeding, as their safety during pregnancy or breastfeeding has not been sufficiently established.
  Have a history of pancreatitis, as both medications may increase the risk of this condition.
- Suffer from severe kidney or liver problems.
- Have a history of certain types of cancer, especially medullary thyroid cancer or multiple endocrine neoplasia type 2 (MEN 2), as there is a potential risk associated with the use of these medications.
Signature*

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Term and Conditions
- I agree that it is my responsibility to inform my provider(s) at Vitaminise Wellness Clinic and any other healthcare providers from whom I receive treatment about all medications prescribed to me.
- I understand that the use of anti-obesity medications may be contraindicated due to certain medical histories, allergies, or other medications I may be using.
- I agree to be honest in disclosing this information and will notify my provider(s) at Vitaminise Wellness Clinic of any changes to my medical history or medication usage.
- I understand that failing to do so could be harmful to my health.
I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo
Date*

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