GLP’s History

6510 Milestrip Road, Orchard Park, NY 14127

GLP-1 Medication Patients (e.g., Semaglutide, Tirzepatide)

Full Name

Date of Birth

Date

Male

Female

Other

Phone Number

Email

example@example.com

Emergency Contact Name: Emergency Contact Phone

Emergency Contact Name

1. Height: 2. Weight: 3. BMI (if known): 4. Do you have a history of any of the following? (Check all that apply)

1 Height

2 Weight

3 BMI if known

Type 2 Diabetes

Type 1 Diabetes

Thyroid cancer personal or family

Pancreatitis

Gallbladder disease

Gastroparesis

Liver disease

Kidney disease

Eating disorder eg anorexia bulimia

Depression or anxiety

Heart disease

High blood pressure

High cholesterol

PCOS

Other

5 List all current medications and dosages

6 Do you have any allergies medication food etc

If yes please list

7. Have you previously used any weight loss medications or injections?

If yes which ones and what was your experience

8 Have you ever been hospitalized for anything if SO when and what for

1 Describe your typical daily diet

2 How often do you exercise

Type of exercise

Occasionally

Frequently

Approximate drinks per week

Occasionally

Daily

If applicable type and amount

1. Date of Last Menstrual Cycle 2. Do you have normal cycles

2 Do you have normal cycles

1 Date of Last Menstrual Cycle

Date

1 Tell us about your familys medical history age general health diseases overweight cause of death

1 What are your primary health or weight loss goals

2. What is your target weight (if applicable)?

lbs

3 What timeline are you hoping to achieve your goals in

4 Have you tried dietexercise programs before

If yes what were the results

Would you be interested in booking a consult with our Registered Dietitian, to help you meet your weight loss goals?

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code