Patient
Intake Form
Personal Information
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Emergency Contact
Medical History
Are you currently pregnant or breastfeeding? (Yes/No)
Do you have a history of diabetes or high blood sugar? (Yes/No)
Have you ever been diagnosed with thyroid cancer or pancreatitis? (Yes/No)
Are you currently being treated for any chronic conditions? (Yes/No)
Weight Management History
Have you used weight-loss medications or treatments in the past? (Yes/No):
Do you currently follow any specific diet or exercise routine? (Yes/No)
Health Screening Questions
Do you have a family history of thyroid tumors, including medullary thyroid carcinoma?
(Yes/No)
Do you have a history of any cardiovascular conditions (heart attack, stroke, high blood
pressure)? (Yes/No):
Have you ever experienced any gastrointestinal issues, such as frequent nausea, vomiting, or
gallbladder problems? (Yes/No):
Have you experienced rapid weight loss in the past? (Yes/No):
- Yes
- No
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- Yes
- No
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Lifestyle Information
- Yes
- No
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- Yes
- No
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Goals and Expectations
What is your primary goal for starting Semaglutide/Tirzepatide therapy?
GLP-1 Semiglutide doctors visit. This price includes the Doctor Review, Supplies and Meds. Price does not include shipping or tax. This is a monthly subscription service that will renew every 21 days.
GLP-1 Tirzepatide doctor's visit. This price includes the Doctor Review, Supplies and Meds.
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Informed Consent
By signing below, I confirm that the information provided is accurate to the best of my knowledge. I acknowledge that I have been informed about the potential benefits and risks of Semaglutide/Tirzepatide treatment, and I consent to undergo this therapy under the guidance of a licensed medical professional.
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