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GLP 1 - Weight Management
Amazing Meds is here to help you achieve optimal health with our specialized services, including Bioidentical Hormone Replacement Therapy (BHRT), Testosterone Replacement Therapy (TRT), Hormone Growth Therapy (HGH), Anti-Aging, Sports Medicine, Functional Medicine, Primary Care, Weight Management, In-Person and Telehealth, and more. To ensure we provide the best personalized care, we need to collect some initial information. This helps us understand your specific needs. Let's get started on your journey to a healthier, happier you!
If you do not qualify for Semaglutide GLP-1 treatment, you can still qualify for other Weight Management Programs!
Looking forward to seeing you! Have questions? Contact us through Text: (855) 436-5457 or Call (719) 266-5800 MST | Email: support@amazing-meds.com if you have any questions and concerns
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First Name
*
Date of Birth
*
Sex Assigned at Birth
*
Female
Male
Email
*
Phone
*
*We will call to confirm address information and prescription details.
Address for Medication Delivery
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
*We cannot serve patients in Louisiana or Mississippi.
Last Name
*
Unit of measurement
*
Imperial
Metric
Height (cm)
*
Weight (kg)
*
Height
*
Feet
Inch
*
Inches
Weight (lbs)
*
BMI
You Are
We need some health information that will help determine the best GLP-1 Treatment for you
Have you seen your primary care provider in the past 12 months?
*
Yes
No
What do you want to accomplish with Weight Loss Medication? Select all that apply
*
Lose weight
Improve my general physical health
Improve another health condition
Increase confidence in my appearance
Increase energy for activities I enjoy
I have another goal not listed above
My weight is negatively impacting my quality of life
*
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
Because of my weight...
*
I don’t feel like myself
I lack confidence in my appearance
I’m not able to do physical activities I enjoy
I’m not able to complete my daily activities I need to accomplish (for example, errands or chores)
I don’t have enough energy
I feel stressed
I’m not able to wear the clothes that I want
None of the above
I feel judged by others
*Select all that apply
Health Information
Are you currently pregnant, breastfeeding, or planning to become pregnant?
*
Currently breastfeeding
Currently pregnant
Planning to become pregnant in the next 2 months
None of the above
Planning to become pregnant this year
Cardiovascular Health
Do you have, or have you ever been diagnosed with, any heart or heart-related conditions?
*
Yes
No
Atrial fibrillation or flutter
*
Yes
No
Tachycardia (episodes of rapid heart rate)
*
Yes
No
Heart failure
*
Yes
No
Heart disease, stroke, or peripheral vascular disease
*
Yes
No
Prolonged QT interval
*
Yes
No
Hypertension (high blood pressure)
*
Yes
No
Hyperlipidemia (high cholesterol)
*
Yes
No
Hypertriglyceridemia (high triglycerides)
*
Yes
No
Other heart rhythm issues or ECG abnormalities
*
Yes
No
Kidney and Liver Health
Do you currently have, or have you ever been diagnosed with, any hormones, kidney, or liver conditions?
*
Yes
No
NASH) Inch or
Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
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Yes
No
Personal history of thyroid cancer
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Yes
No
Family history of thyroid cancer
*
Yes
No
Chronic kidney disease
*
Yes
No
Kidney stones
*
Yes
No
Fatty liver disease (NAFLD or NASH)
*
Yes
No
Liver cirrhosis or end stage liver disease
*
Yes
No
Hypothyroidism (low functioning thyroid)
*
Yes
No
Hyperthyroidism (high thyroid function)
*
Yes
No
Graves’ disease
*
Yes
No
Other thyroid issues
*
Yes
No
Polycystic Ovarian Syndrome (PCOS)
*
Yes
No
Syndrome of inappropriate antidiuretic hormone (SIADH)
*
Yes
No
Other Health Conditions
Chronic candidiasis (fungal infections)
*
Yes
No
Eating disorder
*
Yes
No
Gout
*
Yes
No
Hirsutism (excess body hair in women)
*
Yes
No
History of suicide attempt or history of suicidal ideation
*
Yes
No
Lymphedema or chronic lower extremity swelling where other causes have been ruled out
*
Yes
No
Metabolic syndrome
*
Yes
No
Obstructive sleep apnea
*
Yes
No
Osteoarthritis
*
Yes
No
Tinea infections (skin folds)
*
Yes
No
Diabetes
I have Diabetes
*
Yes
No
Diabetes (require insulin)
*
Yes
No
Diabetes (not requiring insulin)
*
Yes
No
Prediabetes (also called insulin resistance)
*
Yes
No
Gastrointestinal Conditions
I have Gastrointestinal Conditions
*
Yes
No
Bariatric surgery
*
Yes
No
Pancreatitis
*
Yes
No
History of delayed gastric emptying or gastroparesis
*
Yes
No
Gallstones or other gallbladder disease
*
Yes
No
Medication History
*Select all that apply
Do you currently take any of the following medications?
*
A GLP-1 agonist such as (but not limited to) semaglutide (Wegovy/Ozempic), liraglutide (Saxenda/Victoza), dulaglutide (Trulicity), tirzepatide (Zepbound/Mounjaro)
Sulfonylureas such as (but not limited to) glipizide (Glucotrol), glimepiride (Amaryl)
Sulfonylureas such as (but not limited to) glipizide (Glucotrol), glimepiride (Amaryl)
Insulin
Warfarin (also called Jantoven or Coumadin) - a blood thinner that usually requires regular lab testing
Meglitinides such as repaglinide or nateglinide
Diuretics such as (but not limited to) furosemide (Lasix), bumetanide (Bumex) Hydrochlorothiazide/HCTZ
Selective Serotonin Reuptake Inhibitor (SSRI) such as (but not limited to) citalopram (Celexa), fluoxetine (Prozac), escitalopram (Lexapro)
Monoamine Oxidase Inhibitor (MAOI) such as (but not limited to) phenelzine (Nardil), selegiline (Emsam)
None of these
Do you have any medication alllergies?
*
Yes
No
List all of your medication allergies
Are you currently taking other any medications not listed in this questionaire, vitamins, dietary supplements, and topical creams?
Other Information
Is there anything else you want your healthcare provider to know about your health?
*
Yes
No
Tell us any additional information your provider should be aware of:
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