Full Name
*
Email
*
What dose of your medication are you taking and how often are you taking it?
How long have you been taking Semaglutide or Tirzepatide?
Are you having fewer cravings for sweet and salty foods?
Yes
No
Are you noticing a reduction in appetite? (please be descriptive)
Are you experiencing any symptoms? (light headedness, nausea, heartburn, stomach issues? Which and how severe?
Any other symptoms or side effects?
How much weight have you lost so far?
Are you happy with your results so far?
Yes
No
How often are you exercising?
Is there anything in your lifestyle you need to improve to help you get further results?
Would you recommend this treatment to a friend or family member if they needed it?
Yes
No
Anything else you would like to share?
Are you interested in learning about our annual Primary Care Program?
Yes
No
Submit