Empathetix Wellness is happy to now offer
Semaglutide Weight Loss Injections
Weight ID
Medical History
Please answer these questions truthfully and to the best of your knowledge. This will allow us to design a treatment plan specifically designed for you. Your honest answers are greatly appreciated.
How would you best describe your gender?
Please Select
Male (including transgender men)
Female (including transgender women)
Prefer Not to Say
Height (Feet)
Height (Inches)
Current Weight (In Pounds)
Goal Weight (In Pounds)
Do you take any medications or supplements?
Please Select
Yes
No
Please list all medications or supplements you are taking:
Do you have allergies to any medications?
Please Select
Yes
No
Please list all medication allergies you have:
Check if you have had any of the following now or in the past:
Type 1 Diabetes
Diabetic Retinopathy
Pancreatitis
ESRD on Dialysis
Medullary Thyroid Carcinoma (MTC)
Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)
Currently Pregnant
Currently Breastfeeding
None
Other
Other medical conditions (please list):
Previous Weight Loss History
Please check all previous weight loss methods you have tried:
Liquid Diets
Keto Diet
Atkins or Low Carb Diets
Diet Pills
Weight Loss Programs
Surgery
None
Other
Other methods (please list):
Finish
Should be Empty: