New Patient Medical Weight Loss GLP1 Intake Form

New Patient Medical Weight Loss GLP1 Intake Form

5301 Alpha Road Suite 34, Room 21 - Dallas, TX 75240 Phone: 214-890-6180 | Fax: 1-214-241-4792 Email: contact@jaenixmedspa.com
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.
PATIENT LOCATION & VISIT TYPE
Where are you physically located at the time of this visit?*

TexasOklahomaFloridaWashingtonIowaColoradoVermontVirginiaConnecticutTennessee
Visit Type Requested*

In‑Person Visit (Texas patients only)Virtual / Telehealth Visit
⚠️ Telehealth services are only provided to patients physically located in one of our currrently licensed states at the time of the visit. Testosterone Replacement Therapy is limited to Texas in-person visit patients only.
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 AnxietyNone
I understand and acknowledge that GLP-1 medications are contraindicated in individuals with a current or prior diagnosis of medullary thyroid carcinoma (MTC), Multiple Endocrine Neoplasia syndrome type 2 (MEN-2), active pancreatitis, or severe gastroparesis. I understand that if I answer “Yes” to any of these conditions, I may not be eligible for GLP-1 therapy and treatment may be withheld or discontinued for medical safety reasons.*

YesNo
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?
What best describes why a compounded GLP-1 medication is being considered or required for your care? (Select all that apply)*

Insurance denied coverage for brand-name GLP-1Brand-name medication cost was not affordable out-of-pocketBrand-name medication was unavailable or on backorderUnable to tolerate standard dose escalation with brand medicationRequired slower titration or micro-dosing not supported by brand medicationExperienced significant side effects with brand-name medicationPrior brand-name GLP-1 was discontinued by previous providerLost access due to insurance, pharmacy, or coverage changesAllergy or sensitivity to inactive ingredients in brand medicationTransitioning from brand-name to compounded for continuity of careOther (please explain)
If "other", please explain:
I understand that compounded GLP-1 medications are considered when brand-name options are not accessible, affordable, or clinically appropriate, and that this will be reviewed and determined by my provider.*

YesNo
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 understand that GLP‑1 medications are not a guarantee of weight loss and results vary.

I understand potential side effects may include nausea, vomiting, diarrhea, constipation, reflux, fatigue, and injection site reactions.

I understand compounded medications are not FDA‑approved but are legally prescribed when clinically appropriate.

I understand I must follow dosing instructions and attend follow‑up visits as recommended.

I confirm I am physically located in an eligible state at the time of my visit.

I understand payment, membership, and refill policies apply.
Signature*

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New Patient Medical Weight Loss GLP1 Intake Form

PATIENT LOCATION & VISIT TYPE

Medical History

Lifestyle & Weight Management Goals

Additional Screening

Consent & Acknowledgment