GLP-1 Pre-Treatment Questionnaire
Please provide your current health details and history to assist in your assessment.
Patient Name
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Date
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Month
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Day
Year
Date
Date of Birth
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Month
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Day
Year
Date
Height
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Weight
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Waist Circumference - Directions: Stand and place a tape measure around your bare abdomen, directly above the top of your hip bone (typically level with your belly button). Keep the tape straight, parallel to the floor, and snug but not compressing the skin. Exhale normally and enter the measurement in inches
Eligibility Criteria
Medical History
Please let us know about any medical conditions you have been diagnosed with (check all that apply)
Type 2 diabetes mellitus
Hypertension
Dyslipidemia
Cardiovascular disease
Obstructive sleep apnea
Osteoarthritis
Fatty liver disease/MASH
GERD (reflux)
Other
Other (please specify)
Weight History
Age when weight problems began
Highest previous weight
Lowest previous weight
Periods of rapid weight gain and triggers
Previous weight loss programs (Weight watchers, Noom, Jenny Craig, etc)
Weight loss goals
Absolute Contraindications
Do you have a personal history of medullary thyroid cancer (MTC)?
*
Yes
No
Do you have a family history of medullary thyroid cancer?
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Yes
No
Do you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?
*
Yes
No
Have you ever had a serious allergic reaction (anaphylaxis, angioedema) to semaglutide or any GLP-1 medication?
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Yes
No
Are you currently pregnant?
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Yes
No
Are you planning to become pregnant in the next year?
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Yes
No
Are you currently breastfeeding?
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Yes
No
Medical History Screening
History of pancreatitis?
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Yes
No
If yes, date of pancreatitis
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Month
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Day
Year
Date
History of gallbladder disease or gallstones?
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Yes
No
Chronic gastrointestinal symptoms (nausea, vomiting, diarrhea, constipation)?
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Yes
No
History of gastroparesis or severe dysmotility?
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Yes
No
Eating Disorders
History of anorexia nervosa?
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Yes
No
History of bulimia nervosa?
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Yes
No
History of binge eating disorder?
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Yes
No
History of night eating disorder?
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Yes
No
Mental Health
History of depression or mood disorders?
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Yes
No
History of suicidal thoughts or attempts?
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Yes
No
Currently receiving mental health treatment?
*
Yes
No
Kidney and Urinary
History of kidney stones (nephrolithiasis)?
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Yes
No
History of kidney disease or impairment?
*
Yes
No
Current kidney function issues?
*
Yes
No
Bone and Muscle Health
History of osteoporosis or osteopenia?
*
Yes
No
History of sarcopenia or muscle weakness?
*
Yes
No
Difficulty with physical activities (sit-to-stand, climbing stairs)?
*
Yes
No
Eye Health
History of diabetic retinopathy?
*
Yes
No
Other eye conditions
Other Medical Conditions
History of bariatric surgery?
*
Yes
No
If yes, type and date
Celiac disease or malabsorption conditions?
*
Yes
No
History of previous nutrient deficiencies?
*
Yes
No
Current Medications
Please list all current medications you are taking
Are you currently on hormone therapy (estrogen and/or testosterone) through The Menopause Clinic?
*
Yes
No
If yes, please list your current hormone therapy regimen (medication, dose, and route).
Lifestyle and Social Factors
Typical meal/snack pattern
Diet and Nutrition
Typical meal/snack pattern
Fast food or processed food consumption (times per week)
Food allergies or intolerances
Cultural or household food preferences
Physical Activity
Current exercise routine (type, frequency, duration)
Resistance/strength training
Yes
No
Sleep
Average hours of sleep per night
Sleep problems or diagnosed sleep disorders
Substance Use
Tobacco use
Yes
No
If yes, amount
Alcohol use
Yes
No
If yes, drinks per week
Other substance use
Patient Understanding and Commitment
Patient Signature
Date
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Month
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Day
Year
Date
Patient Understanding and Commitment
PATIENT UNDERSTANDING AND COMMITMENTI understand that:-Weight loss medications must be used with a reduced-calorie diet and increased physical activity.- Treatment may need to be lifelong to maintain weight loss.- Common side effects include nausea, vomiting, diarrhea, and constipation.- After my initial visit, my ongoing care happens through my symptom tracker and secure messaging instead of scheduled appointments — meaning I can reach my care team and get monitored anytime, without waiting for a visit slot to open up. I understand that titration to a stable dose typically takes 4-5 months, and that my required efficacy checkpoint visit happens 3 months after my dose stabilizes (not 3 months from when I start) — often around month 7-8 overall — with quarterly monitoring after that, and additional visits scheduled only if side effects or lack of response require it. My add-on cost is $75/month through my efficacy checkpoint, dropping to $50/month the billing cycle after that visit, with no cost to be evaluated for eligibility. I also understand The Menopause Clinic does not adjust blood pressure, blood sugar, or other non-GLP-1 medications as part of this program, and I will keep my primary care provider updated as my treatment progresses.- I must discontinue weight loss medications at least 2 months before a planned pregnancy.- If I develop severe or persistent abdominal pain, vision changes, or other signs of a medical emergency, I will go to the nearest emergency room or call 911 right away — I will not wait to hear back from my care team first. I will message my care team afterward so we can follow up.
I understand that GLP-1 therapy is not appropriate for everyone, and eligibility is determined by my provider after a medical assessment.
*
Yes
I understand that GLP-1 Support is a separate add-on from my perimenopause/menopause membership. It includes my initial treatment visit (video, included; in-person available for an additional $50), dose titration management, ongoing monitoring between visits through my symptom tracker and secure messaging (so I don't have to wait for a scheduled appointment), and a required efficacy checkpoint visit 3 months after my dose stabilizes — not 3 months from when I start, since titration typically takes 4-5 months. This add-on costs $75/month through that checkpoint, then drops to $50/month starting the next billing cycle after that visit, on top of my membership, with no cost to be evaluated for eligibility.
*
Yes
I understand that the cost of the GLP-1 medication itself is not included in this add-on and is billed separately through the manufacturer's self-pay program.
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Yes
Patient Signature
Date
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Month
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Day
Year
Date
Submit
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