Weight Loss Monthly Follow-up Questions
C2C Med Spa
Name
First Name
Last Name
Age
Please Select
less than 17
18-20
21-29
30-39
40-49
50-59
More than 60
Gender
Please Select
Female
Male
Prefer not to say
What weight loss medication are you on?
Semaglutide
Tirzepatide
Other
Starting Weight
Goal Weight
Current Weight
Are you taking your medication as prescribed?
Yes
No
Are you experienced any side effects?
Nausea
Constipation
Headaches
Fatigue
Ease joint pain
Other
Please describe any side effects or issues you've noticed
How do you feel about your success this month
Have you missed any doses?
Yes
No
If yes, please explain
Have you made any diet changes? If yes, explain.
Rows
Yes
No
Have you had any mood changes?
Have you added physical activity for in your routine?
Are you following a meal plan?
Would you like more one-on-one coaching
Would you like to schedule a 30 min call?
Submit
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