ASSESSMENT FORM
Full Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
Email Address
example@example.com
What is your gender?
Please Select
Male
Female
N/A
Birth Date
-
Month
-
Day
Year
Date
What is your current weight?
What is your Current Height?
Clients who do not meet the minimum BMI of 25 will not be able to continue with the form.
Please contact (475) 206 - 0144 for more information
How would you describe your overall health?
Do you have any medical problems?
What are you allergic to?
What are your biggest health concerns?
What is difficult to do because of your weight?
What are you unable to do, or avoid doing because of your weight?
What are your health goals?
What worked well for you?
What have you tried to lose weight in the past?
What did not?
Have you been diagnosed with an eating disorder or body dysmorphia in the past?
YES
NO
Are you pregnant or breastfeeding?
YES
NO
N/A
Do you have a history of Type 1 DM?
YES
NO
To the best of your knowledge, are you allergic to semaglutide or another GLP-1 receptor agonist?
YES
NO
N/A
Do you have a personal or family history of medullary thyroid carcinoma?
YES
NO
Do you have a history of multiple endocrine neoplasia syndrome?
YES
NO
Do you have a history of pancreatitis?
YES
NO
When was your last physical exam?
Do you have a history of end-stage renal disease (on dialysis) or known issues with your kidneys?
YES
NO
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
What kind of drugs? How long have you used/been using them?
After signing below this form will be sent to our medical director for review. We will reach out to you once approval or denial is received.
Thank you,
Ctls Staff
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