Imagine Weight Loss and Wellness
Medical History Form
Consultation Date:
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Month
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Date
Name:
First Name
Last Name
DOB:
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Date
Phone:
Format: (000) 000-0000.
Emergency contact name and number:
How did you hear about us?
Current weight:
Goal weight:
Exercise routine:
Prescription meds, supplements and self-prescribed meds:
Allergies:
Medical and Surgical history:
Are you pregnant, plan to be pregnant, or breastfeeding (need to discontinue med 2 months prior to becoming pregnant):
Have you tried Semaglutide or Tirzepatide before (also goes by Ozempic, Wegovy, Rybelsus or Mounjaro and Zepbound)?
Do you have any of these medical conditions:
Diabetes
Pancreatitis
Heart disease (may increase heart rate and decrease blood pressure)
Kidney problems
Medullary Thyroid Carcinoma
Depression or suicidal thoughts
Multiple Endocrine Neoplasia Syndrome
Gallbladder problems
Type 2
Email:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Imagine Weight Loss and Wellness
Consent Form
Use with a reduced calorie meal plan and physical activity.
It is best if medication is taken at night to reduce side effect symptoms.
Contact office if having undesirable side effects.
Do not adjust medication without provider instructions.
Do not share needles or medication.
Administer subcutaneously once a week (the same day every week) into the abdomen, thigh or upper arm). Change area each week.
Drink plenty of water, especially if feeling dehydrated from nausea or diarrhea.
Call for next refill and possible dose adjustment one week prior to when dose needed.
Most common side effects:
Nausea, diarrhea, vomiting, constipation, stomach pain, headache, tiredness, dizziness, feeling bloated, belching, and gas.
Possible side effects:
Thyroid tumors (including cancer) - tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing or difficulty breathing. Do not use if you or any of your family have ever had medullary thyroid carcinoma (MTC) or if you have an endocrine condition called Endocrine Neoplasia syndrome type 2 (MEN 2).
Pancreatitis- May be caused by gallstones or the development of sludge or obstruction in the bile ducts. Call your healthcare provider if develop pain in your left upper abdomen, nausea and fever. Pain may radiate to your back. Pancreatitis may be precipitated by binge-eating or consuming a large meal after a period of dieting. Long-term alcohol abuse is associated with Pancreatitis. Severe pancreatitis may require surgery and may be associated with more serious complications and death.
Kidney problems- In people that have kidney problems, diarrhea and vomiting may cause dehydration.
Depression or suicidal thoughts - Pay attention to mental changes.
Gallbladder problems - Any program resulting in rapid weight loss may precipitate the formation of gallstones, which could lead to cholecystitis (inflammation of your gallbladder), which is a medical urgency or emergency and could require surgery. This is typically because of the rapid weight loss, not the medication you are taking. Call your provider if have pain in your right upper abdomen, fever, nausea, vomiting, yellowing of the skin or eyes, or clay - colored stools.
Serious allergic reactions- Stop using and call your provider right away if you have swelling of your face, lips, tongue, or throat; problems breathing or swallowing; severe rash or itching; fainting or feeling dizzy; or very rapid heart rate. Call if have redness and swelling at injection site.
The use of medications for weight management is indicated for those with a BMI of 30 or higher or a BMI of 27 or higher with other medical conditions. Prescribing medications for patients not fitting these
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criteria is considered "off label" and not "FDA approved". For patients not fitting the BMI criteria for use of appetite suppression medication, you are acknowledging that -
You have put forth a true effort to lose weight through diet and exercise over the past 6 months and have still not achieved your weight loss goals.
Your inability to lose weight is causing significant emotional distress.
You are choosing to enter this medically managed weight loss program voluntarily and hold Imagine Weight Loss and Wellness harmless for use of such medications.
I acknowledge that I understand that the amount of weight loss varies from patient to patient, and is, to a large extent, dependent on each patient's personal motivation and commitment to their diet and exercise plan. There is a risk of regaining the weight you lose if you do not increase your physical activity and continue to follow a low calorie, nutritious diet containing lean proteins and vegetables.
I understand the potential benefits of weight loss, which include:
Decreased risk of heart attack.
Decreased risk of adult onset diabetes mellitus.
Decreased risk of developing arthritis or musculoskeletal conditions that are caused by excessive weight gain.
Increased emotional and psychological well-being.
Decreased risk of developing certain types of cancer.
**I have reviewed the mentioned risks and have determined the benefits outweigh the possible risks. I release any claim in court or any type of complaint that could result from treatment with Imagine Weight Loss and Wellness and will not hold any provider or staff liable. I fully understand this consent form and acknowledge that my questions have been fully answered. I understand that I will be responsible for administering the medication prescribed to me and promise to comply with the dosages and frequency of my medication.
I certify that I am under the regular care of a primary care provider for any other conditions. I will consult with my primary care provider regarding any other condition. I understand that if I do not have a primary care provider, I am encouraged to seek one out.
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