Tirzepatide Intake Form

MEDICAL HISTORY

Please select any relevant conditions below:
Adrenal DisorderAngioedemaAnemia / Blood DisorderAsthmaAutoimmune ConditionBlood Clotting DisorderCancer / History of CancerCholelithiasisDeep Vein ThrombosisDepression / Suicidal IdeationDiabetes (Detail Below)Diabetic RetinopathyEpilepsy / SeizuresGastric / Duodenum UlcerGastroparesisHigh Blood PressureHigh Blood CholesterolHIV / AIDS or HepatitisIBD / IBSInfective EndocarditisKidney Disorder / DiseaseLiver DisorderMental Health ProblemsNeurological DisorderPancreatitis / Other DisorderParathyroid DisorderPhlebitisRenal FailureSubstance AbuseThyroid Disease

CLIENT INTAKE FORM TIRZEPATIDE

Have you or a family member been diagnosed with either of the following?
Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2)Medullary Thyroid Carcinoma

Are you allergic to any of the following?
GLP-1 Receptor AgonistsSodium PhosphateAdhesives / Latex

Other allergens:
YesNo

Are you currently taking blood thinners (i.e., Aspirin/Warfarin), Bexarotene, Gatifloxacin, or any Diabetes medication (i.e. Insulin or sulfonylureas)?
YesNo

Female Medical History
PregnantTrying to ConceiveBreastfeedingPost-MenopauseUsing ContraceptivesOther

Please provide a list of all medications or supplements you take:

HEALTH HABITS

Do you smoke?
YesNo

Do you drink alcohol on a regular basis?
YesNo

How is your activity level?
SedentaryLightly ActiveModerately ActiveVery Active

What methods or interventions have you used to lose weight previously?
DietExercisePrescription MedicationTherapyHerbal Supplements

What factors do you consider contribute to your experience of excess weight?
AlcoholExcess CaloriesFamily HistoryHormonal ChangesLow EnergyMedical ConditionPregnancyPerimenopauseSedentary LifestyleSleep DisruptionsStress/Busy Lifestyle

By signing below, I acknowledge that I have provided complete and accurate information and understand that it will be used to assess my suitability for any treatment. I understand that it is my responsibility to inform the practitioner of any changes to my medical history or skincare routine. I agree to waive all liabilities of the practitioner or employer for any injury or damages incurred due to misrepresentation of my health history

Date

I agree to all the terms of this contract