Semaglutide

Medical Questionnaire

Limited Time: Free Health Intake 100% Online.

$199 Value For Free

Take just 2-4 minutes to answer a few important questions that will assist your physician in determining your tailored Semaglutide Oral or Injectable weight management program. 100% Online.

Semaglutide GLP-1 is the same active ingredient in Wegovy® and Ozempic®. Brands names available, too.

Shipping State

Where do you live?

Height and Weight

What is your height and weight?

Semaglutide GLP-1 Use

Are you currently using Semaglutide GLP-1?

Never used Semaglutide

Not used in the last 30 days

Yes, I use Semaglutide Injections

Yes, I use Semaglutide Oral

Lozenges Use (Troches)

What is the date you last took semaglutide lozenges?

What is the last dosage?

Last Dose Taken

How many weeks have you been on your current dose?

Describe your experience with Semaglutide for weight loss, including any side effects, improvements, challenges, or observations you've encountered.

Prescriptions Upload

Transer Existing Prescription: Upload Cop Of Current Prescription

DOB

What is your date of birth?

Date of Birth must be the same as on government ID. Minimum Age Requirement of 21 Years of Age or Older

Gender

What is your gender?

Male

Female

Pregnancy

Are you pregnant?

Yes

Last Menstrual Date

When was your last Menstrual Date?

If no recent menstrual date, select from below:

I am postmenopausal

I have had a hysterectomy

I am pregnant or breastfeeding

I use hormonal birth control that suppresses my cycle

I have a health condition that affects my menstrual cycle (please specify below)

Other reason (please specify below)

Tobacco

Do you use tobacco?

Yes

Cancer History

Do you have a history of cancer?

Yes

Thyroid Cancer History

Do you have a history of medullary thyroid cancer?

Yes

Family Cancer History

Does cancer run in your family?

Yes

Diabetic Ketoacidosis

Do you have diabetic ketoacidosis?

Yes

Allergies or Sensativities

Do you have any allergies or sensitivities to medications, foods, or other substances?

Yes

Medications and Supplements

Are you currently taking any medications or supplements

Yes

Surgical Procedures

Have you undergone any surgical procedures before?

Yes

Physician Care

Are you currently under the care of a physician for any other medical conditions?

Yes

Last Note

Please explain if there is anything else we haven't addressed or if you have any further questions, please add them here.

Side Effects

Please review the potential side effects of Semaglutide and check the boxes below to confirm your understanding:

Common Side Effects:

I understand that common side effects may include nausea, vomiting, diarrhea, abdominal pain, and constipation.

Serious Side Effects:

I understand that Semaglutide may cause serious side effects, including:

Hypoglycemia (low blood sugar): Especially if taken with other diabetes medications. I understand that I may only use Semaglutide if my doctor who is monitoring my diabetes is fully aware of my use. It is 100% my responsibility to communicate my use of Semaglutide and ensure my doctor agrees and monitors it as well.
Pancreatitis: Severe stomach pain that does not go away, with or without vomiting.
Gallbladder Problems: Pain in the upper abdomen, fever, yellowing of the skin or eyes (jaundice), or clay-colored stools.
Kidney Issues: Worsening kidney function, especially in patients with pre-existing kidney problems.

Thyroid Tumors:

I understand that Semaglutide has been associated with thyroid tumors in animal studies, and it is unknown if it causes thyroid tumors or thyroid cancer in humans.

Important Considerations:

I understand that I should not use Semaglutide if I have a personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
I understand that I must consult my general in-person healthcare provider before starting Semaglutide, especially if I am pregnant, planning to become pregnant, or breastfeeding.

Action Steps:

I agree to and understand that I must contact my healthcare provider promptly if I experience any side effects or have concerns while taking semaglutide.

Summary:

I agree to inform my primary care doctor about my Semaglutide treatment, as well as any other doctors I am seeing. I will also get blood tests through my own doctor at their recommendation as needed. Please call or text us at 1-888-503-8488 if you have any questions or are unclear about the instructions.

Contact Information

What's the best way for the Doctor to reach you if they have additional questions?

To avoid any discrepancies, please ensure that the information you enter matches the details you used for your payments.

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