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Survey For Current Patients

Semaglutide/Tirzepatide Survey. Please take this survey the day before you inject in the morning.

This survey is for current patients only. Please complete the survey the day before you inject.

Name *

First

Last

Email *

Provider

Please choose the provider who completed your consultation.

Formulation - Choose Your Current Formulation - LOOK AT YOUR VIAL - DOUBLE CHECK YOUR SELECTION PLEASE *

Please be sure to choose the correct formulation. DOUBLE CHECK YOUR SELECTION PLEASE.

LOOK UP - DID YOU PICK THE CORRECT FORMULATION?

Dose *

PLEASE DOUBLE-CHECK THE DOSE YOU ARE REPORTING.

Date of last injection *

Current weight *

How many pounds did you lose this week? *

I need my dose increased *

How are your side effects *

	None	Mild	Tolerable	Moderate	Severe
Nausea	NoneNausea None	MildNausea Mild	TolerableNausea Tolerable	ModerateNausea Moderate	SevereNausea Severe
Constipation	NoneConstipation None	MildConstipation Mild	TolerableConstipation Tolerable	ModerateConstipation Moderate	SevereConstipation Severe
Heartburn	NoneHeartburn None	MildHeartburn Mild	TolerableHeartburn Tolerable	ModerateHeartburn Moderate	SevereHeartburn Severe
Fatigue	NoneFatigue None	MildFatigue Mild	TolerableFatigue Tolerable	ModerateFatigue Moderate	SevereFatigue Severe
Headache	NoneHeadache None	MildHeadache Mild	TolerableHeadache Tolerable	ModerateHeadache Moderate	SevereHeadache Severe
Other (please include in comments)	NoneOther (please include in comments) None	MildOther (please include in comments) Mild	TolerableOther (please include in comments) Tolerable	ModerateOther (please include in comments) Moderate	SevereOther (please include in comments) Severe

Does any of the following apply?

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Additional comments

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