GLP-1 Patient Questionnaire

1
What is your first and last name?* This field is required.
First Name
Last Name
2
In the past 3 months, have you taken a GLP-1 medication (for example, Semaglutide, like Ozempic or Wegovy, or Tirzepatide, like Mounjaro or Zepbound) prescribed by a provider other than NADforWellness?
YESNO
3
What is your Date of Birth?* This field is required.
Date
Month
Day
Year
4
Define Your Goal Here:
What is your current weight in pounds?
How much weight would you like to lose?
5
Are you currently pregnant, planning to become pregnant, or breastfeeding?* This field is required.GLP-1 medications should not be used during pregnancy or breastfeeding due to safety concerns.
YESNO
6
Are you currently taking insulin or other medications for diabetes, or any medication that requires careful timing for absorption?* This field is required.GLP-1 medications may interact with insulin or other diabetes medications.
YESNO
7
Please provide details about your medications.
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Ok
Ok
8
Do you have any liver or kidney conditions or a history of gastrointestinal issues?* This field is required.Impaired liver/kidney function may necessitate dosage adjustments, and GI sensitivity could worsen in some cases.
YESNO
9
Please provide details about your liver/kidney or GI conditions.
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Ok
10
Do you have any cardiovascular conditions, including hypertension or a history of heart disease?* This field is required.GLP-1 medications have cardiovascular benefits but needs to be monitored in patients with heart disease.
YESNO
11
Please provide details about your cardiovascular conditions, hypertension or history of heart disease.
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Ok
12
Do you have a personal or family history of thyroid cancer, pancreatitis, or gallbladder issues?* This field is required.GLP-1 medications are contraindicated in patients with past thyroid issues due to a potential risk of tumors. Other conditions should be evaluated prior to usage.
YESNO
13
Please provide details about your personal or family history of thyroid cancer, pancreatitis, or gallbladder issues.
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Ok
14
Are you taking any anticoagulants or blood thinners?* This field is required.GLP-1 medications may increase the risk of bleeding in patients on anticoagulants.
YESNO
15
Please provide details about your anticoagulants and/or blood thinner medications.
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Ok
16
What's your email address?* This field is required.We ask for your email address so our medical provider can contact you with any questions about your treatment plan. We will not sell or share your information with any third party.
example@example.com
17
Do you currently live in California?* This field is required.
YESNO
18
Thank You!

Thank you for your interest in NADforWellness. At this time, our GLP-1 program is designed for patients beginning treatment through our clinical team, and we are not accepting transfer patients who have previously used GLP-1 medication through another provider.
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Thank You!