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Weight No More GLP-1

Weight Management

Prescreening Questionnaire

Treatment Consent

Do you consent to treatment with a GLP-1 agonist medication (such as Semaglutide or Tirzepatide)?
Yes
No

You understand that compounded formulations may include additional vitamins or

ingredients such as:

• Cyanocobalamin (Vitamin B12)

• Methylcobalamin

• Pyridoxine

• Glycine

• Niacinamide


Potential benefits of GLP-1 therapy may include improved blood sugar control, reduced appetite, weight loss, and decreased cardiovascular risk.


Potential risks and side effects may include, but are not limited to:

• Constipation or diarrhea

• Nausea or vomiting

• Gastroparesis (slowed stomach emptying)

• Mood changes, including suicidal thoughts

• Low blood sugar (hypoglycemia), especially with other diabetes medications


Alcohol use is strongly discouraged while taking these medications.

Do you consent to proceed with GLP-1 treatment, understanding the risks and benefits?
Yes, I understand and consent
No, I do not consent

Age Requirement

Are you between the ages of 18 and 85?
Yes
No

Pregnancy and Fertility Status

Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months?
No
N/A
Yes, breastfeeding
Yes, pregnant
Yes, trying to conceive within the next 2 months

Medical History

Do you have a history of, or are you currently being treated for, any of the following conditions?

Recent Bariatric Surgery

Have you had gastric bypass surgery or sleeve gastrectomy within the last 18 months?
No
Yes, gastric bypass
Yes, gastric sleeve

Medication Allergies

Do you have any medication or drug allergies? (Check all that apply)

Current Medications

What medications are you currently taking? (Check all that apply)

Lifestyle Commitment

Are you willing to make lifestyle changes, including reduced caloric intake and increased physical activity, alongside medication treatment?
Yes
No

Email Consent

Do you consent to receive pre-treatment and post-treatment information via email?
Yes
No

Prior GLP-1 Side Effects

Have you previously experienced serious or uncontrollable side e_ects from Semaglutide, Tirzepatide, or compounded formulations?
No
Yes (please describe):

Height

Weight

Current Side Effects

Are you currently experiencing any side effects?
No side effects
Yes (please describe):

Current GLP-1 Use

Are you currently taking a GLP-1 medication?
No
Yes — Tirzepatide/Semaglutide (dose and last dose date):

If yes, please indicate if Tirzepatide or Semaglutide and add dose + last dose date.

Dose Adjustment Preference

If currently taking a GLP-1 medication, what dose change would you prefer? (Provider will determine appropriate titration.)
N/A — Not currently taking GLP-1 medication
Increase dose
Stay at current dose
Decrease dose

Additional Considerations

Please select any of the following that apply:
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