Past Hospitalizations/Surgeries

Supplements

List all supplements you're currently taking including vitamins, herbs, minerals.

Food Allergies

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Major Medical Contraindications to GLP-1 Medications

Please note that if you answer yes to any of these questions, you will not be able to take GLP-1 medications like Tirzepatide (Zepbound) or Semaglutide (Wegovy).

GLP-1 Meds Are Popular Because They Work!

In clinical trials, semaglutide users lost an average of 15% of their body weight - with 1 in 3 users losing over 20%+

* Based on the average weight loss in three 68-week clinical trials of patients without diabetes who reached and maintained a dose of 2.4 mg/week of GLP-1 treatment, along with a reduced- calorie diet and increased physical activity. See details. Results may vary based on starting weight and program adherence. Medication prescriptions are at the discretion of medical providers and may not be suitable for everyone. 

Safety info: GLP-1 medications are used to treat obesity or overweight (with weight-related problems), along with diet and exercise. They may have serious side effects, including possible thyroid tumors. Do not use if you or your family have a history of a type of thyroid cancer called MTC or MEN 2.

+ Wegovy® is FDA-approved for weight loss. Ozempic® is FDA-approved for type 2 diabetes treatment but may be prescribed for weight loss. The trademarks, service marks, trade names (Wegovy®, Ozempic®), and products displayed on this Internet site are protected and belong to their respetive owners.

Read the following for more information about this product and its potential side effects

The traditional use of weight loss medications is for individuals with a BMI of 30 and above or to those who are overweight who have associated health conditions. Using it for someone with a BMI range (27-29) without an accompanying health condition is termed "off-label." Using a medication "off-label" refers to the practice of prescribing a drug for a purpose, age group, dosage, or form of administration

Indication for Use

You are requesting treatment with a GLP-1 (Ozempic, Wegovy, or compounded semaglutide) or GIP/GLP-1 receptor agonist (Mounjaro, Zepbound, or compounded tirzepatide) medication as part of your treatment plan for the management of weight or obesity. These medications work by mimicking the action of incretin hormones, which help regulate blood sugar levels, promote feeling full, and reduce food intake.
Potential Benefits
* Weight loss or weight management
* Improved blood glucose control
* Reduced cardiovascular risk
* Potential improvement in overall metabolic health

Potential Side Effects
While these medications can be beneficial, they may also cause side effects. Although not common, these medications can result in emergency room visits, hospitalizations, or even death. Common and serious side effects include, but are not limited to:
* Common Side Effects:
* Nausea
* Vomiting
* Diarrhea
* Constipation
* Decreased appetite
* Indigestion
* Serious Side Effects:
* Pancreatitis (inflammation of the pancreas)
* Hypoglycemia (low blood sugar), especially when used with other diabetes medications
* Gallbladder disease (e.g., gallstones)
* Kidney problems
* Allergic reactions (e.g., rash, itching, swelling)
* Gastroparesis (paralysis of the bowels)

Risks and Considerations
* Pancreatitis: There is a risk of developing pancreatitis. If you experience severe abdominal pain, nausea, or vomiting, you should contact your healthcare provider immediately.
* Thyroid Tumors: Animal studies have shown an increased risk of thyroid tumors with certain GLP-1 medications. Although this has not been confirmed in humans, please inform your healthcare provider if you have a history of thyroid cancer.
* Hypoglycemia: When taken with other diabetes medications, particularly insulin or sulfonylureas, there is a risk of low blood sugar. It is important that your provider knows if any of these medications are added to your regimen. 
* Kidney Function: This medication may affect kidney function, particularly in patients with existing kidney disease. Regular monitoring of kidney function may be required.

Monitoring and Follow-up
You will require regular follow-up visits to monitor your response to the medication and to assess for any side effects. We may intermittently ask for full-body selfie images to ensure that your reported weight is consistent.
I acknowledge the potential benefits, risks, and side effects of GLP-1 or GIP/GLP-1 receptor agonist medications. I understand the importance of regular monitoring and follow-up appointments. I consent to the use of GLP-1 or GIP/GLP-1 receptor agonist medications as part of my treatment plan for overweight or obesity.

Please attest to the following confirming that all information you have provided to us is true and complete.

Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.