Weight Loss Medication Health History Questionnaire
Do you have any of the following medical conditions? (Check all that apply)
Do you have any of the following medical conditions? (Check all that apply)
Are you currently taking any of the following medications?
Are you currently taking any of the following medications?
Have you ever experienced any of the following? (Check all that apply)
Have you ever experienced any of the following? (Check all that apply)
Do you have a family history of any of the following conditions? (Check all that apply)
Do you have a family history of any of the following conditions? (Check all that apply)
Have you previously attempted any weight loss programs or medications? (If yes, please specify):
*
Have you previously attempted any weight loss programs or medications? (If yes, please specify):
How long have you been struggling with weight management?
*
How long have you been struggling with weight management?
How often do you exercise?
*
How often do you exercise?
Describe your typical diet
*
Do you have any dietary restrictions? (Check all that apply)
Do you have any dietary restrictions? (Check all that apply)
Consent and Acknowledgment
By signing below, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that this questionnaire is used to help determine my eligibility for weight loss medications, including Ozempic and Wegovy.
