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Weight loss form
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Sex
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Male
Female
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In case of emergency, please contact:
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Do you have any medication or food allergies?
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Yes
No
If Yes, please list (including reaction)
Are you pregnant or breastfeeding?
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Yes
No
Date of last chemistry screen or other lab testing
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Have you ever been told that you have an electrolyte imbalance or other abnormal labs? (Please check all that apply)
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Hypermagnesemia (High magnesium levels)
Hypercalcemia (High calcium levels)
Hypokalemia (Low potassium levels)
Hemochromatosis (High iron levels)
Are you a diabetic?
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Yes
No
Are you a smoker?
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Yes
No
If yes, how much do you smoke?
How many alcoholic drinks do you consume in a week?
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Do you use any recreational drugs?
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Yes
No
If Yes, which ones and how often?
Please list everything you are currently taking: Prescription Medications – Strength – Frequency-Condition being treated
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Over the Counter Drugs – Strength – Frequency – Condition being treated
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Vitamins and Other Supplements – Strength – Frequency – Condition being treated
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Do you take Digoxin (Lanoxin) for a heart problem?
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Yes
No
Do you take any diuretics or water pills?
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Yes
No
If Yes, please list:
Do you take any steroids, i.e. Prednisone?
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Yes
No
If Yes, please list:
Do you have any of the following conditions? (Please check all that apply)
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History of pancreatitis
Kidney Disease/Kidney Insufficiency
Stomach problems (semaglutide may exacerbate symptoms
Personal or family history of Medullary Thyroid Carcinoma (MTC)
Personal or family history of Multiple Endocrine Neoplasia type 2 (MEN)
Taking any other diabetic related medications
Depression or Suicidal thoughts ***
List any other medical conditions you have (not mentioned above):
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List of all surgical procedures you’ve had with approximate dates:
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Is there anything else you’d like the nurse and physician to know?
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If you are human, leave this field blank.
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