Page 1 of 2
Weight Loss Medication Health History Questionnaire
Client Information
*
*
*
*
Emergency Contact
*
*
*
Medical History
Do you have any of the following medical conditions? (Check all that apply)
Diabetes or blood sugar problems
Hypertension (High Blood Pressure)
Heart Disease
Stroke
Kidney Disease
Liver Disease
Thyroid Disorders
Mental Health Disorders (e.g., depression, anxiety, eating disorders)
Gastrointestinal Disorders (e.g., ulcers, inflammatory bowel disease)
Cancer (If yes, please specify):
Other (Please specify):
Are you currently taking any of the following medications?
Insulin
Oral Hypoglycemic Agents (e.g., metformin, sulfonylureas)
Blood Pressure Medications
Antidepressants
Hormonal Medications (e.g., thyroid hormones, contraceptives)
Other (Please list):
Have you or your family member ever had any of the following conditions? (Check all that apply)
Medullary thyroid cancer (MTC)
* MEN2 syndrome
Weight History
Current Weight
*
Height
*
*
Weight Goal
*
Have you previously attempted any weight loss programs or medications? (If yes, please specify):
*
A
Yes
B
No
How long have you been struggling with weight management?
*
A
Less than 1 year
B
1-3 years
C
3-5 years
D
More than 5 years
Lifestyle Assessment
How often do you exercise?
*
A
Daily
B
3-5 times a week
C
1-2 times a week
D
Rarely/Never
Describe your typical diet
*
Do you have any dietary restrictions? (Check all that apply)
Gluten-free
Dairy-free
Vegetarian
Vegan
Low-carb
Other (Please specify)
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.
*
*
Submit
