Medical History Form

Semaglutide (GLP1, Ozempic, Wegovy) and Tirzepatide (GLP1-GIP, Zepbound, Mounjaro)

Please ensure that all information you provide is accurate, as it will be reviewed by your doctor to develop a personalized treatment plan.

By continuing you accept our terms of service

ATTENTION: Please have your Drivers License (required), Photo of Self (required) and any Medical Labs (optional) ready to upload

ID Verification

We'll need a clear picture of a valid ID or drivers license so we can make sure the data you provided is accurate.

Let's get your current height and weight.

Weight(lb)

Height (Feet)

Height (inches)

Please enter your blood pressure reading within the last 6 months (Ex: 120/80)

You can get it checked for free at most pharmacies. Don't worry; you can skip this for now and provide it later for medication approval.

Systolic (top)

Diastolic (bottom)

Any medical conditions your doctor should know about?

Yes - Please list your medical conditions No - I affirm I have no known medical conditions

Medical Conditions

Are you taking any medications?

Many medications have interactions. Your doctor needs to know every medication that you take to help avoid any harmful interactions.

Yes - Please list the names and dosages No - I affirm I'm not taking any medications

Current Medications

Do you have any drug allergies or intolerances?

Yes - Please list your drug allergies and any known reaction No - I affirm I have no known drug allergies

Drug Allergies

Are you here to be evaluated for weight loss?

All responses will be evaluated by a board-certified provider. Medication may be prescribed for appropriate candidates.

Yes No

Are you here for Semaglutide or Tirzepatide?

Yes No

Have you ever attempted to lose weight in a weight management program?

Examples may include caloric restriction through diet, exercise, or behavior modification.

Yes No, this would be my first time

Are you willing to reduce your caloric intake alongside medication?

Yes No

Are you willing to increase your physical activity alongside medication?

Yes No

Are you CURRENTLY taking any PRESCRIPTION medications for weight loss?

Which medication are you requesting?

Semaglutide (Ozempic® / Wegovy® / Compounded) Tirzepatide (Mounjaro® / Zepbound® / Compounded)

Have you used GLP Semaglutide or Tirzepatide medication before?

No, I am new to this medication Yes, I have used it before

If requesting a higher dose, what was your last known dose?

What is your goal weight?

Please answer in pounds

When was the last time you had an in person medical evaluation?

We want to make sure you have recently been evaluated in person by a healthcare provider.

Less than a year ago 1 to 2 years More than 2 years ago

Have you had any lab tests completed within the last 6 months that you would like to share with your doctor?

Yes No, not at this time

OPTIONAL:
Your doctor only needs to see cholesterol levels, TSH (thyroid test), HbA1c, and Creatinine (kidney function).

Any additional labs which you upload will not be reviewed. The doctor who ordered these labs is in charge of interpreting them.

Do you have any of the following?

These are considered 'co-morbidities" by the American Board of Obesity Medicine. While you may not need to have one of these for treatment, vour doctor would like to know.

Does anyone in your family have a history of...

MENS-2 (Multiple Endocrine Neoplasia Syndrome Type 2) Medullary Thyroid Cancer NONE of the above

Do you have any of the following?

If you have any of the following you should not take semaglutide with B12 (cyanocobalamin).

Leber Optic Nerve Atrophy Cyanocobalamin Hypersensitivity (allergy) Niacinamide Hypersensitivity (allergy) Benzyl Alcohol Allergy NONE of the above

Do you have any of the following?

History of Kidney Failure History of Chronic Renal Failure Seen a Kidney Specialist in the past 12 months History of Solitary Kidney or Kidney Transplant NONE of the above

Please read the following about all GLP-1s

HOW THEY WORK: Increasing insulin production from the pancreas. Decreasing glucagon release after a meal. Glucagon triggers your liver to store fat. Slows gastric emptying, which will make you feel 'full'.
BENEFITS: GLP-1's have been shown to help with weight reduction when combined with lifestyle medications such as exercise and reduction of caloric intake.
RISKS: Medicines in the GLP family have caused thyroid tumors in lab mice. It is not yet known if they will cause thyroid tumors or medullary thyroid carcinoma (MTC) in people. No studies have confirmed a linkage between GLP-1's and thyroid tumors in humans. Sublingual GLP-1's may have a slightly higher chance of abdominal discomfort and/or constipation.
COMMON SIDE EFFECTS: Nausea, constipation, gastro-esophageal reflux, diarrhea, fatigue. Side effects typically lesson the longer the person takes the medication and may be most intense when first starting the medication or immediately following a dosage increase.
RARE SIDE EFFECTS: Depression and hair loss. YOU SHOULD NOT USE A GLP-1 IF YOU HAVE ANY OF THE FOLLOWING: Eating Disorder, Gallbladder Disease (does not include Gallbladder Removal/Cholecystectomy), Severe Gl disease (eg: Gastroparesis, Crohns, Ulcerative Colitis), Drug Abuse, Alcohol Abuse, Recent Bariatric, Surgery Chronic Pancreatitis or Pancreatitis while taking a GLP-1| Personal or family history of Medullary Thyroid Cancer, Multiple Endocrine Neoplasia Type 2 Syndrome (MENS-2), Currently Pregnant (or planning to become pregnant), Currently Breastfeeding and Retinopathy

YES, I CONSENT to being treated with GLP-1 and/or GIP medication. I have reviewed the risks and benefits above. NO, I DO NOT consent to being treatedwith GLP-1 and/or GIP medication

Would you like a prescription of nausea medication to be sent to your local pharmacy?

This is not covered thru this program and therefore will be an extra cost, however generally is not an expensive medication (approx. $10).

Yes. I understand this is different than the medication to help with appetite suppression/weight loss which will be sent directly to me. I will need to go pick this up and pay for it with my own insurance or out of pocket. No, Thank you

Do you understand all the questions which were asked?

Yes No

Please type your FULL LEGAL NAME in lieu of your signature below after reviewing:

Semaglutide (Wegovy®, Ozempic®), Tirzepatide (Zepbound®, Mounjaro®), and Saxenda® belong to a class of medications known as **GLP-1 receptor agonists** and **GIP/GLP-1 co-agonists**. These medications help regulate blood sugar and support weight loss by:

Increasing insulin secretion from the pancreas
Decreasing glucagon release after meals, which reduces fat storage by the liver
Slowing gastric emptying, helping you feel fuller longer

BENEFITS:

In a 68-week clinical trial of 1,961 adults with obesity or excess weight and a related medical condition, those taking **semaglutide (Wegovy®)** with diet and exercise achieved an average weight loss of approximately 12% (~38 lbs), versus ~2.5% (~6 lbs) with placebo. Average starting weight: ~232 lbs.
83% of adults on Wegovy® lost ≥5% of their body weight compared to 31% on placebo.
In the **SURMOUNT-1 study** (Tirzepatide/Zepbound®), adults on the highest dose of tirzepatide lost **up to 22.5% of their body weight** (average ~52 lbs) over 72 weeks. The study included adults with obesity or overweight and at least one weight-related condition.
Weight loss from these medications has been shown to reduce the risk of type 2 diabetes, cardiovascular disease, osteoarthritis-related joint pain, and other obesity-related conditions.

RISKS:

Common side effects include nausea, vomiting, diarrhea, constipation, heartburn, and occasional fatigue or headache.
In animal studies, GLP-1 medications caused thyroid tumors in rodents. It is not known whether they cause thyroid tumors or medullary thyroid carcinoma (MTC) in humans.
No human studies have confirmed a direct link between GLP-1 medications and thyroid cancer, but individuals with a personal or family history of MTC or MEN2 should consult their primary care provider before use.

Please provide a current, FULL body clothed photo of yourself.

This is a requirement for weight loss therapy.
We take your privacy seriously and all photos are secured.
You can also upload a recent (last 1 month) photo from your camera roll or record a short video of yourself.

Here's your first message to your doctor. Please introduce yourself and feel free to:

Ask any questions you have
List any medical problem you have which were not discussed above
Include anything else you would like the doctor to know. We are excited to help you!

Why do we need this?

When practicing telemedicine, it is required that a patient's identity be verified before we prescribe any treatment. This is to make sure that you are the patient filling out your information and receiving treatment just like if you were in a doctor's office in person. We take your privacy very seriously, and all of your information is encrypted and stored in a HIPAA compliant manner.

Please take a photo of the front of your government issued ID, which includes name, date of birth, and picture. Make sure to adjust the lighting and focus so it's easy to read. This will ensure that your doctor can efficiently evaluate and complete your request for treatment.

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Semaglutide (GLP1, Ozempic, Wegovy) and Tirzepatide (GLP1-GIP, Zepbound, Mounjaro)

Please enter your blood pressure reading within the last 6 months (Ex: 120/80)