Monthly Patient Check-In
Response Required Prior to Upcoming Appointment
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Last Appointment Date
*
-
Month
-
Day
Year
Date
Next Appointment Date
*
-
Month
-
Day
Year
Date
Height
*
Current Weight
*
Goal Weight
*
As of TODAY, how much weight have you lost since your last visit?
*Listed in lbs - Weight loss since previous visit
As of TODAY, how much weight have you lost since you started treatment?
*Listed in lbs - TOTAL weight loss since first treatment
Which Medication Are You Taking?
Semaglutide
Tirzepatide
If taking Semaglutide, what is your current dosage?
Please Select
5 units
10 units
15 units
20 units
25 units
30 units
35 units
40 units
48 units
*Please refer to previous months label
If taking Tirzepatide, what is your current dosage?
Please Select
2.5mg
5mg
7.5mg
10mg
12.5mg
15mg
*Please refer to previous months label
Based on the DAILY CALORIE INTAKE goals you received at your initial visit, are you currently:
OVER Goal
AT Goal
UNDER Goal
Based on the DAILY PROTEIN INTAKE goals you received at your initial visit, are you currently:
OVER Goal
AT Goal
UNDER Goal
Based on the DAILY WATER INTAKE goals you received at your initial visit, are you currently:
OVER Goal
AT Goal
UNDER Goal
Have you experienced any new medical problems since your last visit?
Yes
No
Have there been any changes in your medication since we last met?
Yes
No
Are you experiencing any side effects such as nausea, heartburn, or constipation?
Yes
No
If you are experiencing side effects, please list which ones are the most frequent.
Do you perform cardiovascular exercises on a WEEKLY basis?
*
Please Select
Yes
No
What type of exercises are you currently doing?
How many total minutes are you performing cardiovascular exercises weekly?
*Total number of minutes performing cardiovascular exercises weekly
Do you perform resistance training exercises on a WEEKLY basis?
*
Please Select
Yes
No
*Weight training, body weight exercises, resistance bands, etc
What type of exercises are you currently doing?
How many total minutes are you performing resistance training exercises weekly?
*Total number of minutes performing resistance training exercises weekly
Are you interested in additional medication to supplement your weight loss?
Yes
No
Submit
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