MSB Weight Loss Form
Do you have a current Primary Care Physician? If yes, please list their name below:
Primary Care Physician:
Do you have allergies to any medicine? If yes, please list them below:
Please list out all allergies:
Are you currently taking any medication? Please list your current medications:
Do you have a history of heart disease? Diabetes? Kidney disease? Thyroid disease? Autoimmune disease? Or any other chronic disease?
Please explain the history of any diseases you have:
Do you have a family history of Pancreatitis?
Do you have a family history of thyroid cancer?
Do you have a family history of Multiple Endocrine Neoplasia?
Have you ever taken weight loss medication?
If yes, explain when and what below:
What is your height?
What is your current weight?
What is your lowest adult weight?
What is your goal weight?
Are you actively pregnant?
Are you actively attempting to become pregnant?
Are you attempting to become pregnant within the next 3 months?
Semaglutide is a human-based glucagon-like peptide-1 receptor agonist prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.
While using Semaglutide, it is highly recommended that you:
Do not take this medication if:
Possible drug interactions: Anti-diabetic agents, specifically: Insulin and Sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® (THIS IS NOT AN ALL-INCLUSIVE LIST). Other medications used in diabetes, please tell your provider about any medications that may lower your blood sugar.
Possible side effects: Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease. Subcutaneous Injections: common injection site reactions characterized by itching, burning at site of administration with or without thickening of the skin(welting). If you notice other side effects not listed above, contact your doctor or pharmacist.
A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing. Report adverse side effects to your doctor or pharmacist. In the event of any emergency, call 911 immediately.
By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results.
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Document Name: MSB Weight Loss Form
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