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what services are you interested in?
Hair restoration
Weight loss
Weight
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Height
Feet
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Inches
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Total height in inches
Contraindications
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Medullary Thyroid Cancer
MEN2
Pancreatitis or pancreas disease
Gallstones or other gallbladder disease
Kidney disease
Liver disease
IBS or IDB
Hypoglycemia
Retinopathy
Alcohol misuse or abuse
Significant depression
Suicidal ideation
Eating disorder
None of the above
Semaglutide may impact these conditions so it is important that we know.
Other medical conditions
None
Previous GLP-1 agonist?
Yes
No
Results or adverse reaction to previous GLP-1 agonist
Contraindicate medications
Insulin
Metformin
Sulfonylureas such as glipizide (Glucotrol) or glimepiride (Amaryllis)
Megalitinides such as repaglinide or nateglinid
Directics such as furosemide (Lasix), bumetanide (Bumex) or Hydrochlorothiazide (HCTZ)
Bexarotene
Gatifloxicn
None of the above
Select all that apply
Other medications
None
Prior weight loss interventions
Sleeve gastrectomy
Laparoscopic adjustable gastric band (Lap-Band)
Roux-en-Y gastric bypass
Gastric balloon
Other procedure
None of the above
Select all that apply.
Past Surgeries
None
Family planning in next 6 months
(Required)
Yes
No
