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Doctor-Guided Wellness Program
A licensed medical provider designs a personalized protocol built around your body and your goals. Fully online, completely private, supported every step of the way.
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Step
1
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Personal Information
Patient Name
*
Date of Birth
*
Occupation
*
Current weight (kg)
*
Current height (cm)
*
Contact #
*
Preferred teleconsult schedule
*
Date
Time
Latest laboratory results (if available)
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Personal Medical History
First time using GLP-1?
Yes
No
Start date
Last date taken
Current dose: mg
*
Target weight: kg
*
Next
Questions
Any history of heart, lung, or kidney problems?
*
Do you have diabetes, thyroid issues, or pancreatitis?
*
Any recent gallbladder concerns or surgeries?
*
If yes, please specify:
Any history of severe gastrointestinal issues (e.g., gastroparesis, severe reflux, stomach ulcers)?
*
Have you had unexplained abdominal pain, nausea, or vomiting recently?
*
Any recent changes in vision (for patients with diabetes, due to risk of retinopathy worsening)?
*
Are you currently taking any medications or supplements?
*
Do you have any known allergies or previous reactions to medications?
*
Are you currently pregnant, breastfeeding, or planning to become pregnant?
*
*
Your personal and medical information is protected under the Data Privacy Act of 2012.
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