New Patient Medical Weight Loss GLP1 Intake Form

New Patient Medical Weight Loss GLP1 Intake Form

📋 Please fill out, sign, and submit the intake form prior to your consultation.
Name

First NameMiddle NameLast Name
Birthdate

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Medical History
Do you have any of the following conditions? (Check all that apply)

Type 1 DiabetesType 2 DiabetesThyroid Disease (Hypothyroidism/Hyperthyroidism)Personal or family history of Medullary Thyroid Cancer (MTC)Personal or family history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)PancreatitisGallbladder DiseaseKidney DiseaseLiver DiseaseGastroparesis or Severe GI Motility DisorderCardiovascular Disease (Heart Attack, Stroke, High Blood Pressure)History of Eating Disorders (Anorexia, Bulimia)Depression or AnxietyOther
Do you take any daily medications, prescribed or over the counter?

YesNo
If yes, please list all current medications & supplements (Please list all)
Do you have any medication allergies?

YesNo
If yes, please list all known allergies.
Have you previously used a GLP-1 receptor agonist (Semaglutide, Tirzepatide, Ozempic, Wegovy, Mounjaro, etc.)?

YesNo
If yes, which one have you tried in the past, when was your last dose, and what was your dose at the time?
Do you currently take insulin or other diabetes medications?

YesNo
If yes, please list.
Are you currently pregnant, trying to conceive, or breastfeeding?

YesNo
Lifestyle & Weight Management Goals
What is your current weight? ___________ lbs
What is your height? ___________ ft _____ in
What is your goal weight? ___________ lbs
What is your primary reason for seeking GLP-1 therapy?

Weight lossBlood sugar controlAppetite suppressionOther
If other, please list.
How many times per week do you exercise?

None1-2 times3-4 times5+ times
Do you follow any specific diet plan?

No specific dietLow carb/KetoMediterranean dietIntermittent fastingOther
Do you consume alcohol?

NoYes, occasionallyYes, frequently
Do you smoke or use tobacco/nicotine products?

NoYes
Do you use any recreational drugs, including marijuana?

NoYes
Additional Screening
Have you ever had any of the following weight loss procedures?

Gastric SleeveGastric BypassLap BandOther
If other, please list.
Have you had any significant weight fluctuations in the past year?

YesNo
Do you experience frequent nausea, vomiting, or acid reflux?

YesNo
Do you have any history of hypoglycemia (low blood sugar)?

YesNo
Consent & Acknowledgment
I acknowledge that GLP-1 medications are not a quick fix and require adherence to lifestyle changes for the best results.

I understand that side effects may include nausea, vomiting, diarrhea, and potential GI discomfort.

I confirm that I have provided accurate and honest health information.

I acknowledge that I must follow up regularly for monitoring and adjustments as needed.
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New Patient Medical Weight Loss GLP1 Intake Form

Medical History

Lifestyle & Weight Management Goals

Additional Screening

Consent & Acknowledgment