Weight Management condensed intake HamiltonHealthWellness

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Past Medical Problems

Desired Treatment or Medication

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

Yes No NA

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

Yes No NA

Have you been diagnosed or had pancreatitis , liver disease or kidney disease ?*

Yes No

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

Yes No

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

Yes No

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

Yes No

Have you had bariatric surgery in the last year?

Yes No

Have you ever been diagnosed with Type 1 diabetes? (usually diagnosed during childhood)?

Yes No

Have you ever been diagnoised with Type 2 diabetes?

How did you hear about us?

Hi there! Looks like you are ready for a refill. To make sure we are treating you safely, please answer the following questions. Answering ALL of the questions will help us facilitate your refill faster than an incomplete check-in.

Have you noticed a decrease in appetite?

Requested medication and dose

Changes in medical history

What was your last injection date?

Consider the next dose if you have not lost weight, have been hungry before day 7 and tolerated your current dose without side effects. Again, decide based on your appetite suppression, and stay on the lowest effective dose as long as possible. More is not always necessarily better in this case. If requesting a retail medication please indicate the name and address of your pharmacy below

Refill Questionairre