Patient Questionnaire Patient Questionnaire for Weight Loss First Name(Required) First Last Name(Required) Last Sex Age Date of Birth(Required) MM slash DD slash YYYY Your Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred Method of ContactEmailPhoneYour Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Referred by HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?(Required) Depression, history of or Diabetic retinopathy, history of or Digestion problems or Kidney disease or Type 2 Diabetes (for patients using Wegovy®) – use with caution. May make these conditions worse. Diabetic ketoacidosis (ketones in the blood) or Type 1 Diabetes – Should not be used in patients with these conditions. Insulin is needed to control these conditions Multiple endocrine neoplasia syndrome type 2 (MEN 2) or Thyroid cancer, history of Pancreatitis (inflammation of the pancreas), history of None of the above Are you currently taking:(Required) Semaglutide (Ozempic®) Tirzepatide (Mounjaro®) None of the above Have you been taking that medication for three (3) or more months? YES NO Which medication are you requesting?(Required) Semaglutide Tirzepatide Patient Informed Consent for Weight-Management Medications (Please Read Completely and Carefully)(Required) I agreeI understand it is my responsibility to follow the instructions carefully and to report to the physician treating me for my weight any significant medical problems that I think may be related to my weight-control program, as soon as reasonably possible. Also, I will notify the physician of all medication I am taking, including anti-depressant medications and herbal supplements. I understand the purpose of this treatment is to assist me in my desire to decrease my body weight and to maintain this weight loss. I understand that my continuing to receive the weight-management medication will be dependent on my progress in weight reduction and weight maintenance. I understand there are other programs that can assist me in my desire to decrease my body weight and to maintain this weight loss. In particular, a balanced-calorie counting program or an exchange-eating program without the use of the weight-management medication likely may prove successful if followed, even though I probably will be hungrier without the use of a weight-management medication. Risks of Proposed Treatment I understand this authorization is given with the knowledge that the use of the weight-management medication can have the following side effects: Side Effects • Belching. • bloated, full feeling. • excess air or gas in the stomach or intestines. • gaseous stomach pain. • heartburn. • passing gas. • recurrent fever. • stomach discomfort, fullness, or pain. Risks Associated with Obesity I am aware that there are certain risks associated with remaining overweight or obese. Among them are tendencies for high blood pressure; diabetes; heart attack and heart disease; and arthritis of the joints, hips, knees and feet. I understand these risks may be modest, however, these risks can increase significantly the more overweight I am. No Guarantees I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I also understand that I will have to continue monitoring my weight all of my life, if I am to be successful. Consent I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained, or any questions have not been answered to my complete satisfaction. I acknowledge that I have been given time to completely read and understand this form. If you have any questions as to the risks or hazards of the proposed treatment, or any questions concerning the proposed treatment or other possible treatments, please ask now before signing this consent form.Date(Required) MM slash DD slash YYYY Your Comments/Questions
