Virtual Psychiatric Care
GLP-1 Weight Loss
Pre-Screen Questionnaire
Answer a few quick questions to see if this program may be right for you. This takes about 2 minutes and will not be stored or shared.
Question 1 of 12
Question 1 of 12
Understanding of risks
Do you understand that GLP-1 medications (including semaglutide or tirzepatide, and compounded formulations) may carry risks including gastrointestinal side effects, gastroparesis, gallbladder concerns, pancreatitis, mood changes, suicidal thoughts, and low blood sugar?
Question 2 of 12
Age requirement
Are you between the ages of 18 and 85?
Question 3 of 12
Pregnancy / breastfeeding / trying to conceive
Are you currently pregnant, breastfeeding, or trying to conceive within the next 2 months?
Question 4 of 12
Height & weight
Enter your current height and weight to check your BMI. New patients starting GLP-1 treatment must have a BMI of 25 or higher.
Your BMI will appear here.
Question 5 of 12
Medical history
Do you have a history of, or are currently being treated for, any of the following conditions?
Medullary thyroid cancer (or first-degree family history)
Multiple Endocrine Neoplasia Syndrome Type 2 / MEN 2 (or first-degree family history)
Pancreatitis, gastroparesis, intestinal ileus, or severe chronic constipation
Acute gallbladder disease
Advanced kidney or liver disease
Active Crohn's disease or ulcerative colitis
Type 1 diabetes, uncontrolled type 2 diabetes, A1c above 10, or diabetic retinopathy
Spontaneous or idiopathic low blood sugar
Uncontrolled thyroid disorder
Abnormal or unexplained weight loss
Anorexia, bulimia, or active eating disorder
Active substance abuse
Suicidal thoughts or behavior
Other uncontrolled serious medical condition
Question 6 of 12
Recent bariatric surgery
Have you had gastric bypass or gastric sleeve surgery within the last 18 months?
Question 7 of 12
Medication or ingredient allergies
Are you allergic to any of the following?
Semaglutide or tirzepatide
Any GLP-1 medication
Cyanocobalamin / B12 or Methylcobalamin
Pyridoxine, Glycine, or Niacinamide
Question 8 of 12
Current diabetes medications
Are you currently taking any of the following medications?
Insulin
Glipizide, Glyburide, or any sulfonylurea
Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro), or Synjardy
A GLP-1 medication combined with diabetes medication
Question 9 of 12
Prior serious side effects
Have you previously experienced serious, severe, or uncontrollable side effects from semaglutide, tirzepatide, another GLP-1 medication, or compounded medication ingredients?
Question 10 of 12
Current symptoms
Are you currently experiencing any of the following?
Severe nausea or vomiting
Severe or persistent abdominal pain
Severe constipation
Symptoms of dehydration
New or worsening mood changes
Suicidal thoughts
Any other severe or concerning symptoms
Question 11 of 12
Lifestyle commitment
Are you willing to make lifestyle modifications — including reduced caloric intake and increased physical activity — alongside medication treatment?
Question 12 of 12
Email communication consent
Do you consent to receive required pre-treatment and post-treatment education, safety instructions, and follow-up information by email?