GLP-1 Assessment

Patient Profile

Full Name *

Email Address *

Phone Number *

Date of Birth *

Gender *

Female Male

Are you currently pregnant or breastfeeding? *

Yes No

Height and Weight *

ft

in

lbs

BMI: Enter height and weight above

Assessment

Have you ever had an adverse or allergic reaction to any GLP-1 receptor agonist? *

Semaglutide (Ozempic, Wegovy) Tirzepatide (Mounjaro, Zepbound) Dulaglutide (Trulicity) Exenatide (Byetta, Bydureon) Liraglutide (Victoza, Saxenda) Lixisenatide (Adlyxin) Other GLP-1 medication No, I have never had an adverse reaction

Are you taking any of the following medications? *

Insulin secretagogues (sulfonylureas, meglitinides) Insulin None of the above

Please upload a photo of your current prescription bottle *

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Please type in your current medication along with the strength and dose *

Are you currently taking any GLP-1 medications? *

Yes No

Please upload a photo of your GLP-1 prescription bottle *

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Please type in your current medication along with the strength and dose *

Do you have any of the following medical conditions? *

Pancreatitis Gastroparesis or delayed gastric emptying Diabetic ketoacidosis None of the above

Do you currently have a known HbA1C >8%? *

Yes No

How much alcohol do you typically consume? *

None Light (1-2 drinks per week) Moderate (3-7 drinks per week) Heavy (8+ drinks per week)

Do you have family history of Multiple Endocrine Neoplasia Type 2 or Medullary Thyroid Carcinoma? *

Yes No

Upload full-body photos *

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Medical History

What is your exercise level? *

High Low Moderate

Do you have any allergies? *

Yes No

If yes, please list your allergies *

Do you currently use tobacco or vape? *

Yes No

What type of tobacco/vaping products and how frequently? *

Are you currently receiving chemotherapy? *

Yes No

Are you currently experiencing depression with history of suicidal attempts, thoughts, or ideation? *

Yes No

Verification

Address *

City *

State *

Postal Code *

Upload government ID (driver's license) for identity verification *

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GLP1 Assessment

Patient Profile

Assessment

Medical History

Verification