Combined Intake HamiltonHealthWellness

Patient Intake Form

Reason for Visit

Patient Education (Please Read)

* ABOUT GLP-1 Therapy (MOUNJARO, SEMAGLUTIDE, OZEMPIC, etc):
• GLP-1 therapy is contraindicated in patients with a history of pancreatitis.
• GLP-1 therapy is contraindicated for use in patients with type 1 diabetes mellitus.
• GLP-1 therapy is contraindicated for patients with a personal or family history of Medullary Thyroid Cancer or Type 2 Endocrine Neoplasia.

The most common side effects of GLP-1 include nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, headache, and stomach (abdominal) pain. These are not all the possible side effects of GLP-1 use.

👉🏽👉🏽 DO NOT USE/ CONTRAINDICATIONS TO GLP-1 THERAPY:
* Do not use GLP-1's if you OR any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or Type 2 Endocrine Neoplasia.
* GLP-1 therapy is also contraindicated if you have a history of or are currently diagnosed with pancreatitis, kidney disease, or Type 1 diabetes.
* GLP-1's are contraindicated in those who are pregnant, planning to become pregnant, or breastfeeding.
* GLP-1 therapy may reduce the effectiveness of your birth control pill. Consider non-oral contraception or add a barrier method after each dose escalation.
Link for education:
https://hopkinsdiabetesinfo.org/medications-for-type-2-diabetes-glp-1-agonists

Our weight-loss prescriptions are sent out monthly. This is done to monitor your weight and address any potential side effects that may arise. By doing this, we can make necessary dosage adjustments to ensure that your weight loss journey is safe and effective. Please message us after your third injection so we can evaluate your therapy, discuss your progress, and possibly adjust your dosage.

👉🏽 Please note that Mounjaro and Ozempic are only covered by insurance if you have Type 2 Diabetes.
🌟🌟If your insurance does not cover weight loss medications, we offer affordable alternatives such as compound Semaglutide (available in oral and injectable forms) and compound Tirzepatide.

Patient Education (Please Read)

PDE-5 Inhibitors for Erectile Dysfunction - Patient Education
Viagra (sildenafil), Cialis (tadalafil), Stendra (avanafil), Levitra (vardenafil)
1. Understanding PDE-5 Inhibitors: PDE-5 inhibitors are medications that help improve blood flow to the penis, making it easier to achieve and maintain an erection. They work by blocking the action of an enzyme called phosphodiesterase-5 (PDE-5), which regulates blood flow.
2. Types of PDE-5 Inhibitors: Commonly prescribed PDE-5 inhibitors include sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra). These medications have similar effects but may differ in onset of action, duration of effectiveness, and potential side effects.
3. It's essential to consult your Primary Care Physician before starting any treatment for ED. Your in-person doctor will verify compatibility with your other medications and can follow up with you closely while on this medication, which is a limitation of telehealth.
4. Dosage and Timing: These medications are usually taken about 45 minutes to an hour before sexual activity.
5. Sexual Stimulation is Required: PDE-5 inhibitors enhance the natural response to sexual stimulation. They do not cause spontaneous erections; sexual arousal is necessary for them to work.
6. Potential Side Effects: Common side effects of PDE-5 inhibitors include headache, flushing, nasal congestion, upset stomach, and back pain. These side effects are usually mild and temporary. However, if you experience severe or persistent side effects, contact your healthcare provider.
7. Interaction with Other Medications: Make sure your medical history is up to date and completed accurately, including prescription drugs, over-the-counter medications, and herbal supplements. PDE-5 inhibitors can interact with certain medications, especially nitrates used for chest pain, potentially leading to dangerous drops in blood pressure.
8. Avoid Alcohol and Grapefruit: Alcohol and grapefruit products can interact with PDE-5 inhibitors, potentially affecting their effectiveness. It's advisable to limit alcohol intake and avoid grapefruit while taking these medications.
9. Follow-Up Appointments: Regularly follow up with your in-person healthcare provider to assess the effectiveness of the medication and address any concerns. Adjustments to the dosage or treatment plan may be made based on your response.
10. Storage and Disposal: Store PDE-5 inhibitors according to the instructions provided on the medication packaging. Do not share your medication with others, and dispose of unused or expired medication properly.

Remember, individual responses to PDE-5 inhibitors may vary. It's essential to communicate openly with your in-person healthcare provider throughout the treatment process to ensure safe and effective management of erectile dysfunction. DO NOT TAKE NITRATES WHILE ON THIS MEDICATION, AS THIS CAN BE FATAL. MONITOR YOUR BLOOD PRESSURE BEFORE TAKING THIS MEDICATION, AND DO NOT TAKE IF YOUR BLOOD PRESSURE IS LESS THAN 110/60. THIS MEDICATION WILL DROP IT EVEN FURTHER AND CAN BE FATAL.

Name

Date of Birth

Patient Address

Patient City

Patient State

Patient Zip Code

Patient Phone

Height

Weight

Blood Pressure

Allergies

Current Medications

Please list any past medical problems.

Surgical History

Are you pregnant, planning to become pregnant, breastfeeding, or bottle-feeding using breast milk?

Pregnant Planning to become pregnant Breastfeeding No N/A

What are your symptoms?

What treatments have you tried?

What is your goal weight?

Do you have a personal or family history of thyroid cysts, cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2?

Yes No

If yes, please explain.

Have you ever had pancreatitis?

Yes No

If yes, please explain.

Have you been diagnosed with liver or kidney disease?

Yes No

If yes, please explain.

Current or prior suicidal thoughts and/or major depression?

Yes No

If yes, please explain.

Do you have an active diagnosis or are you currently being treated for cancer?

Yes No

If yes, please explain.

Do you have a history of organ transplant and/or currently on immune-suppressing medication?

Yes No

If yes, please explain.

Do you have a severe gastrointestinal condition ex: IBS, gastroparesis, bowel obstruction?

Yes No

If yes, please explain.

Have you ever had bariatric surgery before?

Yes No

If you had bariatric surgery when?

Have you been diagnosed with Type 1 diabetes? If so, are you on insulin?

Yes, NOT on insulin Yes, currently on insulin No

Have you been diagnosed with Type 2 diabetes?

Yes No

Are you allergic or sensitive to medications, particularly sildenafil or other phosphodiesterase type 5 (PDE%) inhibitors?

Yes No Unknown

List all medicatons you currently take, including over-the-counter and herbal supplements. This is important to check for potential drug interactions.

Have you had any recent eye problems or vision loss?

Yes No

If yes, please explain.

Have you been diagnosed with liver or kidney disease?

Yes No

If yes, please explain.

Are you currently experiencing any penile abnormalities, such as Peyronie's disease or priapism (prolonged erection)?

Yes No

If yes, please explain.

Have you experienced any recent cardiovascular problems, such as a heart attack, stroke, or irregular heart rhythm?

Yes No

If yes, please explain.

Do you have any bleeding disorders, or are you taking anticoagulant medications?

Yes No

If yes, please explain.

Do you have a history of low or high blood pressure?

Yes No

If yes, please explain.

Are you currently taking medications to manage your blood pressure?

Yes No

If yes, please explain.

Are you currently using any nitrate medications for chest pain (angina) or recreational drugs like amyl nitrate ("poppers")?

Yes No

If yes, please explain.

Was your most recent blood pressure below 110/60 or above 160/90?

Yes No

What medication do you need refilled?

Please list your desired treatment or medication (if known).

Please list your desired dose (if known).

Preferred Pharmacy Name

Pharmacy Address

Pharmacy City

Pharmacy State

Pharmacy Zip Code

Pharmacy Phone

Please scan and upload a copy of your identification.

Are you aware that most insurances will NOT cover GLP-1 medications without meeting very specific criteria?

Yes No

Where did you hear about us?

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