New Client Form
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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1925
1924
1923
1922
1921
1920
Year
Height
*
Weight
*
What is your goal weight?
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Medical History
Do you have a history of any of the following conditions? Please check all that apply.
Type 1 Diabetes
Type 2 Diabetes
Pancreatitis
Thyroid disease
Medullary Thyroid Cancer
Kidney disease
Liver disease
Gallbladder disease
Retinopathy
Gastrointestinal disorders (Crohn's disease, IBS, etc)
Cardiovascular disease (Heart attack, stroke, etc)
Hypertension
Hyperlipidemia
Cancer
Other
Have you ever had any severe allergic reactions?
Yes
No
If yes, please specify your allergies.
Do you have any history of mental health conditions? (Depression, anxiety, etc.)
Yes
No
If yes, please specify your conditions.
If yes, please list medications or supplements.
Are you currently taking any medications or supplements?
Yes
No
Do you take insulin or any other medications for diabetes?
Yes
No
If yes, please list any other medications for diabetes.
Have you taken semaglutide, tirzepatide, or retatrutide or any GLP product in the past? If so, which medication and for how long? Any adverse side effects?
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Lifestyle & Habits
Do you smoke?
Yes
No
If yes, how many cigarettes a day?
Do you consume alcohol?
Yes
No
If yes, how many drinks per week?
How often do you exercise?
Daily
3-4x per week
1-2x per week
Rarely
Never
Describe your typical diet.
Balanced (includes fruits, vegetables, proteins, healthy carbs)
High in carbohydrates
High in fats
High in proteins
Other
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Specific Concerns & Goals
What is your primary goal for using semaglutide, tirzepatide, or retatrutide? (Please check all that apply.)
Weight loss
Blood sugar control
Reducing cardiovascular risk
Other
Do you have any other specific concerns or conditions that you would like to address while on semaglutide/tirzepatide/retatrutide?
Yes
No
If "Yes," please specify.
Do you have any other specific concerns or conditions that you would like to address while on semaglutide/tirzepatide/retatrutide?
Yes
No
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Consent & Understanding
Do you understand the potential side effects and risks associated with semaglutide use, tirzepatide use, or retatrutide use?
*
Yes
No
By signing below, you acknowledge that you have read and understand the potential side effects and risks associated with semaglutide use, and you accept these risks.
*
Have you discussed semaglutide, tirzepatide, or retatrutide use with your healthcare provider?
Yes
No
Do you agree to follow up with regular medical check-ups and laboratory tests as recommended by your healthcare provider?
Yes
No
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Declaration
By signing below, you acknowledge that the information provided is true and complete to the best of my knowledge.
*
Who referred you to MK Medical Wellness?
Submit
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