NewClientForm - MK Medical Wellness

New Client Form

First name

Last name

Email

Phone number

Date of birth

Height

Weight

Have you ever had any severe allergic reactions?

Yes No

If yes, please specify your allergies.

Do you have any history of mental health conditions? (Depression, anxiety, etc.)

Yes No

If yes, please specify your conditions.

Are you currently taking any medications or supplements?

Yes No

If yes, please list them.

Do you take insulin or any other medications for diabetes?

Yes No

If yes, please list them.

Do you smoke?

Yes No

If yes, how many cigarettes a day?

Do you consume alcohol?

Yes No

If yes, how many drinks per week?

Describe your typical diet.

If other, please specify.

What is your primary goal for using semaglutide? (Please check all that apply.)

Weight loss Blood sugar control Reducing cardiovascular risk Other

If other, please specify.

Do you have any other specific concerns or conditions that you would like to address while on semaglutide?

Yes No

If yes, please specify.

Do you have any other specific concerns or conditions that you would like to address while on semaglutide?

Yes No

Do you understand the potential side effects and risks associated with semaglutide use?

Have you discussed semaglutide use with your healthcare provider?

Yes No

Do you agree to follow up with regular medical check-ups and laboratory tests as recommended by your healthcare provider?

Yes No

I declare that the information provided is true and complete to the best of my knowledge.