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4 week assessment

Please complete the following assessment in order to receive your next dose of medication. Thanks! 

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Question 1 of 12

Please enter the information below:

Your name, email address, current height and weight  

Question 2 of 12

Please list the date of your last injection taken. 

Question 3 of 12

What dosage are you currently taking? 

A

0.25 mg semaglutide

B

0.5 mg semaglutide

C

0.75 mg semaglutide

D

1 mg semaglutide

E

1.5 mg semaglutide

F

2 mg semaglutide

G

2.5 mg tirzepatide

H

5 mg tirzepatide

I

7.5 mg tirzepatide

J

10 mg tirzepatide

K

12.5 mg tirzepatide

Question 4 of 12

Are you experiencing side effects? Select all (or none) that apply 

(Select all that apply)
A

Nausea

B

Constipation

C

Vomiting

D

Diarrhea

E

Bloating

F

Abdominal pain / cramping

G

Gas

H

Fatigue

I

None of the above

Question 5 of 12

On a scale of 1-5, with 1 being somewhat tolerable and 5 being intolerable, how severe are the side effects you're experiencing from your current medication?

A

1

B

2

C

3

D

4

E

5

F

N/A - not experiencing adverse side effects

Question 6 of 12

On average, how many ounces of water per day are you consuming? 

A

Less than 32 oz a day

B

32-48 oz a day

C

48-64 oz a day

D

64-100 oz a day

E

100 oz or more a day

Question 7 of 12

Select how many calories you are consuming on average daily 

A

Less than 1,000 calories / day

B

1,100 calories a day

C

1,200 calories a day

D

1,300 calories a day

E

1,400 calories a day

F

1,500 calories a day

G

1,600 calories a day

H

1,700 calories a day

I

1,800 calories a day

J

1,900 calories a day

K

2,000 calories a day

L

Greater than 2,000 calories a day

Question 8 of 12

Please list how many grams of protein you consume daily, on average. 

(Ex: I consume 90 grams of protein daily). 

Question 9 of 12

Provide a quick dietary recall (1 day of eating) from the past week: 

Breakfast, lunch, dinner & snacks. 

Question 10 of 12

How many minutes of exercise are you getting per week? 

(Minimum recommended is 150 active minutes per week) 

Question 11 of 12

Do you want to increase, decrease, or maintain at your current medication dosage this month? Please select an answer below. 

A

Increase dosage

B

Decrease dosage

C

Maintain on the same dosage

D

Discontinue dosage

Question 12 of 12

If you have any questions, comments, concerns, or would like a phone call, please request below.

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