Semaglutide Initial Intake Form

Empathetix Wellness is happy to now offer

Semaglutide Weight Loss Injections
Basic Patient Information

To schedule your free, no-commitment phone consultation with our doctor.
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you best describe your gender?
Height (Feet)
Height (Inches)
Current Weight (In Pounds)
Goal Weight (In Pounds)
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.
Do you take any medications or supplements?
Please list all medications or supplements you are taking:
Do you have allergies to any medications?
Please list all medication allergies you have:
Check if you have had any of the following now or in the past:

Type 1 DiabetesDiabetic RetinopathyPancreatitisESRD on DialysisMedullary Thyroid Carcinoma (MTC)Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)Currently PregnantCurrently BreastfeedingNoneOther
Other medical conditions (please list):
Previous Weight Loss History
Please check all previous weight loss methods you have tried:

Liquid DietsKeto DietAtkins or Low Carb DietsDiet PillsWeight Loss ProgramsSurgeryNoneOther
Other methods (please list):
What are your goals for treatment? Do you have any specific concerns you would like addressed?
*

I acknowledge that all the information is true and accurate to the best of my knowledge.
How did you hear about Empathetix?
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Basic Patient Information

Medical History

Previous Weight Loss History