GLP-1 Intake Form: Learn2Lose Weight Loss in Charlotte

GLP Patient Intake Form

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Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Height (inches)(Required)

In inches - example: 5'4" = 64 inches

Weight (lbs)(Required)

BMI

Biologic sex(Required)

Which location are you going to?(Required)

Ballantyne

Matthews

Virtual/Telemed

GLP-1 Contraindications

Do you have a personal history of pancreatitis, medullary thyroid carcinoma (MTC), or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?(Required)

Yes

Details: Specify the condition (e.g., pancreatitis, MTC, MEN 2), diagnosis date, and any relevant medical history.(Required)

Do you have a family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)? (Note: Family history refers to parents, siblings, or children with these conditions.)(Required)

Yes

Details: Specify the condition (e.g., MTC, MEN 2), the family member affected (e.g., parent, sibling), and any known genetic testing results (if applicable).(Required)

Gastrointestinal History

Have you ever experienced significant nausea, vomiting, heartburn, or stomach discomfort from medications or supplements?(Required)

Yes

Which medications caused issues?(Required)

How often do you experience these symptoms?(Required)

Daily

Weekly

Monthly

Rarely

Do you have a history of acid reflux, heartburn, or GERD?(Required)

Yes

How often do you experience heartburn or reflux?(Required)

Daily

Weekly

Monthly

Rarely

Do you take medication for acid reflux or heartburn?(Required)

Yes

Which medication(s) do you take for acid reflux or heartburn?(Required)

Have you ever taken Metformin (Glucophage)?(Required)

Yes

Did you experience any side effects with Metformin?(Required)

Yes

Please list any side effects from Metformin(Required)

Are you currently taking Metformin (Glucophage)?(Required)

Yes

Do you have a history of slow digestion, gastroparesis, or other motility issues?(Required)

Yes

Explanation: feeling full for a long time after eating or having food sit in your stomach for a while

When were these issues diagnosed?(Required)

Have you experienced delayed stomach emptying symptoms with any medications including?(Required)

Yes

Have you experienced changes in bowel habits (e.g., diarrhea or constipation) with medications or dietary changes?(Required)

Yes

How often do you have a bowel movement?(Required)

2 or more times per day

Once a day

2–3 times per week

Less than 2 times per week

Do you experience loose stools or diarrhea regularly?(Required)

Yes

How frequently do you experience loose stools or diarrhea?(Required)

Do you experience constipation regularly?(Required)

Yes

Do you take stimulant laxatives or stool softeners?(Required)

Yes

Have you been diagnosed with any of the following gastrointestinal conditions?(Required)

Irritable bowel syndrome (IBS)

Inflammatory bowel disease (IBD)

Crohn’s disease

Ulcerative colitis

Celiac disease

Gastroparesis

Peptic ulcer disease

GERD

Other

None of the Above

Please check all that apply

Prior GLP-1 Experience

Have you previously used a GLP-1 medication (e.g., Ozempic, Wegovy, Mounjaro, Zepbound, Byetta, Victoza, Saxenda or compounded)?(Required)

Yes

Which GLP-1's have you taken?(Required)

Semaglutide (Ozempic, Wegovy, Rybelsus, Compounded)

Tirzepatide (Mounjaro, Zepbound, Compounded)

Byetta (exenatide), Victoza/Saxenda (liraglutide)

Check all that apply

Did you experience any side effects or worsening symptoms while taking GLP medications? (Check all that apply)(Required)

Nausea

Vomiting

Diarrhea

Constipation

Abdominal pain

Heartburn / GERD

Headaches

Loss of appetite

Dizziness

Fatigue

Injection site reaction

Other

None of these

Check all that apply

Vitamin and Nutrient Status

Have you had bloodwork showing anemia, low B12, or low iron levels?

Yes

Which one(s)? (Check all that apply)

Anemia

Low Vitamin B-12

Low Iron

Have you experienced any of the following symptoms, which could suggest low B12 or impaired metabolism?(Required)

Fatigue or weakness

Muscle weakness, soreness, or poor recovery

Numbness or tingling in extremities

Brain fog or difficulty concentrating

None of the above

Check all that apply

Do you have any of the following risk factors for Vitamin B-12 deficiency? (check all that apply)(Required)

Follow vegan or vegetatian diet

Digestive disorders (Conditions like celiac disease, Crohn's disease, and atrophic gastritis can impair the absorption of vitamin B12)

Autoimmune diseases (Certain autoimmune diseases can affect the body's ability to absorb B12)

Sjögren's syndrome (People with Sjögren's syndrome are over six times more likely to have vitamin B12 deficiency)

Chronic alcohol use

Past Bariatric Surgery (bariatric surgery can reduce stomach acid, which is necessary for B12 absorption)

Metformin use

GLP-1 medications

Acid lowering drugs (PPI's, Prilosec, Zantac, Pepcid)

None apply to me

Medication Tolerability and Injection Preferences

Many people have experienced, or heard about others experiencing, side effects such as nausea, stomach issues, and fatigue from GLP-1 medications. Would you be interested in exploring alternative dosing schedules (such as smaller, more frequent doses) to help reduce or avoid these side effects?(Required)

Yes

Are you comfortable with self-injection?(Required)

Yes

Do you prefer a smaller needle or syringe over an auto-injector?(Required)

Yes

Doesn't matter

Have you experienced injection site reactions or tolerability issues (e.g., pain, swelling, bruising, scarring, redness, itching or irritation) with subcutaneous GLP-1 injections that might suggest a need for a different formulation?(Required)

Yes

Describe the reaction(s) you experienced, their impact on your ability to continue the medication, and any attempts to improve the reaction (e.g., changing injection sites, using a different needle size, using Benadryl or hydrocortisone for itching or swelling).

Are you willing and able to self inject if you were given specific education on how to do it?(Required)

Yes

GLP Patient Intake Form

GLP-1 Contraindications

Gastrointestinal History

Prior GLP-1 Experience

Vitamin and Nutrient Status

Medication Tolerability and Injection Preferences

Medical Weight Loss

TELEMEDICINE

CHARLOTTE NC WEIGHT LOSS CLINIC

MATTHEWS NC WEIGHT LOSS CLINIC