Weight Loss Clinic Intake Screening Form for GLP-1 Medication

Weight Loss Clinic Intake Screening Form for GLP-1 Medication

Please fill out this form to help us assess your suitability for GLP-1 weight loss therapy.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Residential Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Age*
Sex at birth*

MaleFemaleIntersex
Do you have any allergies to food, medications, plants etc? Please indicate below and list the items you are allergic to and the allergic reaction
Do you have or ever had any of the following medical conditions? (Select all that apply)*

DiabetesDiabetic RetinopathyEating disorder (bulimia, anorexia)GlaucomaHeart DiseaseHigh Blood Pressure (Uncontrolled)Kidney DiseaseMedullay Thyroid CancerMultiple endocrine neoplasia, type 2 (MEN 2)PancreatitisStrokeThyroid DisordersOther
Please specify any other medical conditions or relevant health information.
Are you currently pregnant or breastfeeding?*

YesNo
Are you currently taking birth control pills?*

YesNo
What is your weight loss goal?

Not sure yet, I just know I need to lose weightLose 1 to 15 lbsLose 16 to 49 lbsLose more than 50 lbs
Primary Care Physician Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name of Primary Practice
Date of Last Medical Check-up

MonthDayYear
Date
Are you currently taking any medications? (Select all that apply)*

InsulinBlood Pressure MedicationsThyroid MedicationsOther
Please list any other medications or supplements you are taking.
How did you hear about us?
Signature to confirm the accuracy of the provided information.*

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