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weight loss questionnaire

 

WEIGHT LOSS QUESTIONNAIRE

Name(Required)
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Address(Required)
Are you 18 years of age or older?
Have you been diagnosed with an eating disorder or body dysmorphia in the past?
Are you pregnant or breastfeeding?
Do you have a history of Type 1 DM?
To the best of your knowledge, are you allergic to semaglutide or another GLP-1 receptor agonist?
Do you have a personal or family history of medullary thyroid carcinoma?
Do you have a history of multiple endocrine neoplasia syndrome?
Do you have a history of pancreatitis?
Do you drink alcohol? How many drinks on average per week?
Do you have a history of end stage renal disease (on dialysis) or known issues with your kidneys?
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