GLP-1 Program Screening Questionnaire

Thank you for completing this health questionnaire in preparation for inclusion in the IMC GLP-1 program.

Date of birth *

Are you a current patient of a medical provider at Integrative Medical Clinic of NC? *

Yes

No

Please list any allergies *

Please list any new medications you've started in the last two (2) weeks. *

Do you have a history of sodium (salt) retention or electrolyte imbalance? *

Yes

No

Do you have a history of hypertension (high blood pressure)? *

Yes

No

Do you have a history of diabetes and/or low blood sugar? *

Yes

No

Do you have a history of fainting / seizures / epilepsy? *

Yes

No

Do you have heart failure? *

Yes

No

Have you had any heart surgery? *

Yes

No

Do you have kidney disease? *

Yes

No

Do you have liver disease? *

Yes

No

Are you currently pregnant and/or breastfeeding? *

Yes

No

Have you had a stroke? *

Yes

No

Do you have a bleeding disorder? *

Yes

No

Do you experience headaches? *

Yes

No

Do you have a history of cancer? *

Yes

No

Do you have a history of Medullary Thyroid Cancer? *

Yes

No

Do you have a history of Pancreatitis? *

Yes

No

Do you have a history of ESRD? *

Yes

No

Do you have a history of Hypoglycemia? *

Yes

No

Do you have any history of constipation? *

Yes

No

Do you have any history of a bowel blockage? *

Yes

No

Have you been diagnosed with Osteoporosis or Osteopenia? *

Yes

No

Do you currently track your caloric intake? *

Yes

No

Do you have a history of disordered eating? *

Yes

No

Are you currently taking any thyroid medications or hormone replacement therapy? *

Yes

No

If so, please list below

Please share anything you would like your provider to know.

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