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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.

Please choose the provider who completed your consultation.
Please be sure to choose the correct formulation. DOUBLE CHECK YOUR SELECTION PLEASE.

LOOK UP - DID YOU PICK THE CORRECT FORMULATION?

PLEASE DOUBLE-CHECK THE DOSE YOU ARE REPORTING.
NoneMildTolerableModerateSevere
Nausea
None
Mild
Tolerable
Moderate
Severe
Constipation
None
Mild
Tolerable
Moderate
Severe
Heartburn
None
Mild
Tolerable
Moderate
Severe
Fatigue
None
Mild
Tolerable
Moderate
Severe
Headache
None
Mild
Tolerable
Moderate
Severe
Other (please include in comments)
None
Mild
Tolerable
Moderate
Severe
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