Semaglutide Form

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Patient Information:

Sex:
If female: are you currently pregnant or breastfeeding
May we leave a message on an answering machine or with a family member?
May we email or mail you information on services offered by our office?
MARITAL STATUS
SPOUSE:

PRIMARY INSURANCE:

EMERGENCY CONTACT INFORMATION :
(a relative or friend not living with you):

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PATIENT EMPLOYMENT INFORMATION:

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MEDICAL QUESTIONNAIRE:

Please check additional areas of concern that you would like to discuss with Dr. Gupta:

Body:
Face & Neck:
Other:
SERIOUS MEDICAL PROBLEMS:
CURRENT MEDICATIONS:
Medication One
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Two
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Three
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Four
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Five
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Six
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Seven
Name of Medication:
Dose:
How often:
Date Last Taken:
Medication Eight
Name of Medication:
Dose:
How often:
Date Last Taken:
DO YOU TAKE ASPIRIN ON A REGULAR BASIS?
DO YOU HAVE A PACEMAKER?
Do you take any of the following medications?

  • A GLP-1 agonist such as (but not limited to) semaglutide (Wegovy/Ozempic), liraglutide (Saxenda/Victoza), dulaglutide (Trulicity)

  • Sulfonylureas such as (but not limited to) glipizide (Glucotrol), glimepiride (Amaryl)

  • Meglitinides such as repaglinide or nateglinide

  • Insulin

  • Diuretics such as (but not limited to) furosemide (Lasix), bumetanide (Bumex), Hydrochlorothiazide/HCTZ

  • Selective Serotonin Reuptake Inhibitor (SSRI) such as (but not limited to) citalopram (Celexa), fluoxetine (Prozac), escitalopram (Lexapro)

  • Monoamine Oxidase Inhibitor (MAOI) such as (but not limited to) phenelzine (Nardil), selegiline (Emsam)

ALLERGIES:
Are you allergic to any medication?
What type of reaction do you have?
Do medications have an unusual effect on you?
Are you allergic to adhesive tape?
Are you allergic to iodine?
Please list any other allergies:
Do you have an allergy to GLP-1 agonist medication? *

Examples include liraglutide (Saxenda/Victoza), semaglutide (Wegovy/Ozempic/Rybelsus), and dulaglutide (Trulicity).

HABITS:
Do you have alcoholic beverages more than 2‐3 times per week?
Do you smoke?
How many packs per day?
How many years?

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PAST SURGICAL HISTORY:
Procedure One
Date
Procedure
Surgeon
Procedure Two
Date
Procedure
Surgeon
Procedure Three
Date
Procedure
Surgeon
Procedure Four
Date
Procedure
Surgeon
MEDICAL QUESTIONNAIRE:

PAST MEDICAL HISTORY:
Have you ever had any of the following?:

Do you have a history of any of the following medical conditions?

Do you currently have, or have you ever been diagnosed with, any of the following heart or heart-related conditions?

Do you currently have, or have you ever been diagnosed with, any of these hormone, kidney, or liver conditions?

REVIEW OF SYSTEMS:
Do you now or have you had within the past year any of the following?:

Do you currently have, or have you ever been diagnosed with, any of these additional following conditions?

Are you currently undergoing treatment for an eating disorder, experienced symptoms of an eating disorder within the past 90 days or been diagnosed with any of the following eating disorders within the past 90 days?

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FAMILY HISTORY:​​​​​​

Has anyone in your family had a tendency to bleed extensively?
Has anyone in your family had an unusual reaction to anesthesia?
Has anyone in your family had unexplained fevers following surgery?
Do you have a personal or family history of medullary thyroid cancer?
Do you have a personal or family history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)?
Have you ever had a blood transfusion?
Do you have any metal in your body?
A30master 8:30am - 5:00pm 8:30am - 5:00pm 8:30am - 5:00pm 8:30am - 5:00pm 8:30am - 5:00pm Closed Closed surgeon # # #