GLP-1 Intake Form

First name

Last name

Email

Phone

Birthday

Address

Enter your current weight, height and goal weight

Tell us what you have tried in the past to lose weight

If you have taken a prescription weight loss med in the past, tell us what you tried and about your experience

Which one of our programs are you most interested in? Tirzepatide (active ingredient in mounjaro/ zepbound) or Semaglutide (active ingredient in ozempic/ wegovy)?

Who is your primary care provider?

When was your last routine exam? Did you have blood work done?

List current medications:

Any allergies?

Have you ever had an adverse reaction to any vitamins? If so, which one?

Past surgeries or major illnesses:

Do you have Glaucoma and or Leber's Hereditary Optic Neuritis?

Do you or anyone in your family have pancreatic cancer, thyroid cancer or multiple endocrine neoplasia (Type II), ?

Do you have diabetes?

Do you have liver or kidney disease?

Do you have a history of an abnormal heart rate, rhythm or heart disease?

Do you have a history of bone marrow disorders?

Do you have a history of pancreatitis of gastroparesis?

Do you experience any of the following? Add check if yes

If yes to any of the above, please explain:

This medication is a once a week injection. We will provide patient education on how to safely give yourself the injection at home. Would you feel comfortable doing in home injections, or would you prefer to come into clinic for the weekly injections?

For female patients: When was your last period?

Are you trying to become pregnant?

Have you ever been diagnosed with PCOS?

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