Semaglutide/ Trizepatide form

Semaglutide Intake Form

Please take a minute to fill in the following info

Personal Information First Name: Last Name: Birth Date: Emergency Contact with Phone Number: Email: Phone Number: Address:

Are you under a doctor’s care at the present time?

Yes No

If yes, please list the Dr's name and contact information:

Health Conditions

Do you currently have or have you had any of the following health conditions (check all that apply):

Please list all surgeries and other hospitalizations (Reason, Year, Hospital): Do you have any allergies? If so, please list: Are you currently taking any medications or supplements? If so, please list: Do you have any allergies to medication? If so, please list:

Exercise Habits

Please check next to the best one that describes your exercise habits:

Inactivity - no exercise activity with a sit-down job
Light Activity - no organized physical activity
Moderate Activity - occasionally involved in physical activity
Heavy Activity - heavy construction, lifting, stair climbing or regular physical activity 3x/week
Vigorous Activity - persistent physical exercise for at least 60 minutes 4x/week

Dietary and Lifestyle

Are you currently dieting now?

Yes No

How many meals do you eat in an average day?

Is your daily salt intake?

Low Moderate High

Is your daily caffeine intake?

Low Moderate High

How many cups/cans per day do you drink?

What types of caffeine do you drink:

Coffee Tea Soda None

Do you drink alcohol?

Yes No

If yes, how many times per week?

Do you smoke?

Yes No

If yes, do you smoke:

Cigarettes Other tobacco products

If yes to cigarettes, how many packs per day do you smoke?

*Women Only* - Are you currently pregnant, trying to get pregnant or breastfeeding?

Yes No

Weight Loss Goals and History What is your main reason you want to lose weight? At what age did you begin gaining excess weight? (provide details if possible) What is the main cause of your weight problems? What other weight loss programs and previous diets have you tried? Do you have any food allergies or food you avoid? What foods do you crave most often? Please describe your snack habits:

Do you eat more when you are stressed?

Yes No

What do you feel are your obstacle(s) to successful weight loss?

Consent and Certification

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the service provider or other health professional of my current medical health conditions and to update this history. A current medical history is essential for the service provider to execute appropriate treatment procedures. I have read and understand the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and I will not hold any staff member personally responsible for any errors or omissions that I have made in the completion of this form.

Print Your Name:

The purpose of this informed consent form is to provide written information regarding the risks, benefits and alternatives of the semaglutide injections. This material serves as a supplement to the discussion you have with your service provider. It is important that you fully understand this information, so please read this document thoroughly and put your initials in the appropriate boxes. If you have any questions regarding the procedure, ask your service provider before signing the consent form.

THE TREATMENT

Semaglutide is a weight loss drug that has recently had extensive clinical studies to prove its safety and efficacy. It is an injectable medication that increases your satiety and reduces your food intake. It works by mimicking the effects of insulin in your body which helps slow down the emptying of your stomach and signaling of your brain that your stomach is full, as a result you feel full for longer periods of time and eat less. This is not a quick fix though, you still have to make smart food choices and get your body moving every day. Semaglutide is a once a week injection that can easily fit into your busy schedule. The benefits help reduce hunger pangs and helps you lose weight faster when you combine the injections with a low calorie diet. It is best to take medication at night.