Weight Loss QuestionnairePlease fill out the questions below to better inform our team. Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Occupation * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Confirm Email * Drivers license Number * State issued * Expiration Date * Emergency Contact: Including name and phone number * Why are you interested in Semaglutide/Tirzepatide? * Primary Care Provider Information: Must include Name, Phone Number and address. * Have you every tried Semaglutide or Tirzepatide before? If so, why did you stop? * What is the reason you want to lose weight? * How long has your weight been a problem? * Are you currently at your heaviest weight? (if no, how much did you weight at your heaviest?) * My worst food habit is: * Are you a stress eater? * Yes No Do you eat in the middle of the night? * Yes NO Does your significant other struggle with weight issues? * Yes No What methods have you previously tried to lose weight? * Are you scared of needles, have a needle phobia or faint easily when you have blood taken? * Are you currently trying to conceive or planning to become pregnant in the near future? * Yes No Does not apply Are you currently pregnant? * Yes No Does not apply Are you breastfeeding? * Yes No Does not apply Are you on any type of hormone replacement therapy? * Yes No Does not apply Are you on any contraceptive methods? * Yes No Does not apply List any prescribed, supplements (including vitamins), and over the counter medications you are currently taking * What was the date of your last physical exam? * List hospitalizations, including dates and reasons for hospitalization (including any surgeries) * Yes No List any drug, food or environmental allergies you may have * Are you on any blood thinners? * Yes No Do you currently or have you ever smoked? * Yes No Past of current medical history: Do you have any of the following: * Heart disease (such as heart attack, rheumatic fever, irregular heartbeat, angina, heart murmur, chest pain Disease of the arteries High blood cholesterol Anemia or other blood disorders i.e Sickle Cell disease, Thalassemia History of dizziness, seizures, or stroke Medullary thyroid cancer Any thyroid disease/problems Parathyroid problems or Adrenal gland problems Diabetes or abnormal blood sugar tests Phlebitis (inflammation of a vein) Deep vein thrombosis/blood clot in the leg (DVT) or PE (pulmonary embolism) Gallstones or any gallbladder disease (including jaundice) High blood pressure (hypertension) Severe reflux (acid reflux) Any current breathing problems (such as asthma, COPD, bronchitis) Infective endocarditis Kidney problems including chronic kidney disease Pancreas/digestion problems (including acute or chronic pancreatitis) Stomach/duodenum/gastric ulcer Liver problems (including hepatitis, liver failure, alcoholic liver disease) Any neurological problems (including Parkinson's Disease) Severe stomach/gut problems (inflammatory bowel disease: Crohn's disease or Ulcerative colitis) Irritable bowel syndrome (IBS) Skin conditions (eczema, rosacea, unexplained rashes) Eating disorders (anorexia or bulimia) Mental health problems (personality disorder, psychosis, diagnosis of depression/anxiety/bipolar) Self-diagnosis of depression, low mood, nervous or emotional problems Substance abuse (including alcohol or drugs) None of the above Have you or your blood relatives had any of the following (including grandparents, aunts, uncles, but exclude cousins, relatives by marriage or half-relatives)? * Heart attacks under age 50 Stokes under age 50 High blood pressure Elevated cholesterol Diabetes Asthma or hay fever Skin allergies Congenital heart disease Heart operations Red blood cell disorders i.e. Sickle cell, thalassemia and anemia Glaucoma Kidney Disease Obesity (20 or more pounds overweight) Leukemia or cancer under age 60 Thyroid cancer None of the above Comments Please Type your Full name in this text box. This will serve as your signature. By signing this you agree that you have answered all questions truthfully and to the best of your ability. * Thank you!
