Follow-Up
Answer a few questions so your provider can review your progress.
Demographics
State you currently live in
*
Select state
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Date of birth
*
Current Medication
Which medication are you currently taking?
*
Select medication
Semaglutide (Ozempic/Wegovy)
Tirzepatide (Mounjaro/Zepbound)
What is your current Semaglutide dose?
*
Select dose
0.125mg
0.25mg
0.5mg
1mg
1.7mg
2.5mg
Height & Weight
Height
*
4 ft
5 ft
6 ft
7 ft
0 in
1 in
2 in
3 in
4 in
5 in
6 in
7 in
8 in
9 in
10 in
11 in
Current weight (lbs)
*
Side Effects
Are you experiencing any side effects? (Select all that apply)
*
None of the below applies
Nausea
Vomiting
Diarrhea
Constipation
Fatigue
Hair Loss
Dizziness
Acid Reflux
Gallbladder Issues
Progress
Do you feel like the medication is working?
*
Select
Yes
No
How much weight have you lost since your last medication adjustment?
*
Select
0–5 lbs
5–10 lbs
11–16 lbs
More than 17 lbs
Next Steps
What would you like to do?
*
Select
Stay on Current Med & Dose
Increase Dose (if eligible)
Safety Check
Have you had any of the following since starting treatment?
*
None of the below applies
Severe Vomiting / Dehydration
Uncontrolled Diarrhea
Vision Changes
Unexplained Fatigue / Weakness
Signs of Gallstones (sharp abdominal pain, nausea after fatty meals)
Severe Mood Changes or Depression
Health Updates
Do you have any changes or additions to your medical history?
*
Select
No changes
Yes
Are you taking any new medications?
*
Select
No new medications
Yes
Pregnancy Status
Have you become pregnant since starting treatment?
*
Select
No
Yes
Additional Information
Is there anything else you would like to share with your provider?
*
Nothing to add
Submit Follow-Up
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