Patient GLP-1 Intake Form

First Name *

Last Name *

Email *

Date of Birth *

Phone *

Gender *

Male

Female

Non-Binary

Prefer not to say

Height (in inches) *

Weight (lbs) *

Address

Street Address *

Country *

State *

City *

Postal code *

Reason for visiting Evercurrent?

Do you have Diabetes? *

Do you take a sulfonylurea (glipizide or glyburide) or insulin? *

Have you ever taken GLP-1 drugs before? (semaglutide or tirzepatide) *

Do you have any known medication allergies? *

Do you have a history of any significant medical conditions (e.g., heart disease, diabetes, cancer)? *

Any history of the following? *

Multiple family members with the same type of cancer

Hormone imbalance

Pituitary masses or previous pituitary surgery

NONE OF THE ABOVE

Are you currently pregnant or breastfeeding? *

Any Allergies? *

How would you rate your overall health?

BadGood

How satisfied are you with your current energy levels?

BadGood

Typical Exercise Frequency

RarelyDaily

Acknowledgement *

I have answered the following questions truthfully and to the best of my ability