The weight loss intake form will ask for information that helps the clinician understand whether GLP-1 weight loss treatment may be safe and appropriate for you.
This may include:
Basic information
Your legal name
Date of birth
Sex assigned at birth
State of residence
Contact details
A full-body photo
Weight and health information
Your height and current weight
Any weight-related health conditions, such as high blood pressure, type 2 diabetes, dyslipidemia, or obstructive sleep apnea
Your most recent blood pressure reading
Your most recent resting heart rate
Medication history
Your current medications and allergies
Any prior allergic reactions to medication
Any current or recent GLP-1 medication use, including the medication, dose, and how long you used it
Any weight loss medications you have tried before
Other health information
You will also be asked about other health factors that can affect whether treatment is safe or appropriate. This may include questions about things like thyroid cancer history, pancreatitis, gallbladder disease, kidney disease, pregnancy or breastfeeding status, and certain medications or health conditions.
It’s important to answer as accurately as possible. This helps the clinician review your information and decide whether GLP-1 weight loss treatment may be appropriate.