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Onboarding Form

Are you here to be evaluated for weight loss?
Are you willing to reduce your caloric intake alongside medication?
Are you willing to increase your physical activity alongside medication?
Are you CURRENTLY taking any PRESCRIPTION medications for weight loss?
When was the last time you had an in person medical evaluation?
Have you had any lab tests completed within the last 6 months that you would like to share with your doctor?
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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, your doctor would like to know.

Blood pressure should be listed as follows: Systolic (top number) /

Diastolic (bottom number)lf you are not sure, please go have your blood pressure obtained (often free at your local pharmacy).

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'.

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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.

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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.

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COMMON SIDE EFFECTS:

Nausea, constipation, gastrosophageal reflux, diarrhea, fatigue

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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 familv historv of medullary Thvroid Cancer

Multiple endocrine neoplasia type 2 syndrome (MEN-2)

Currently Pregnant (or planning to become pregnant)

Currently Breastfeeding

Retinopathy

Do you consent to being treated with GLP-1 agonists ?

Thank you! We’ll be in touch.

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