Place Order To TelegraMD GLP Intake Form 1. What is your primary goal for weight loss? Overall health improvement Specific weight loss target Increased energy Improved body compositionContinue2. How much weight would you like to lose? 10-20 lbs 20-30 lbs 30-40 lbs 40-50 lbs 50+ lbsContinue3. How often do you exercise? 1-2 times per week 3-4 times per week 5+ times per week NeverPreviousNext4. Are you willing to follow a weight loss dietary plan/reduce calories and exercise? Yes NoPreviousNextI acknowledge that GLP medications are most effective when used in conjunction with exercise. Yes NoPreviousNext5. Have you had any previous weight loss attempts or programs? Yes NoPreviousNextPlease select the statement that best describes your previous weight loss attempts. Was able to lose weight and kept off the weight for a while Was able to lose weight but regained the weight shortly after Was unable to lose even though I followed my dietary and exercise goals Was unable to lose weight and I was unable to follow my dietary and exercise goalsPreviousNext6. Have you been diagnosed with any eating disorders or have a history of disordered eating? Yes, currently diagnosed Yes, in the past No, but I have experienced disordered eating behaviors No, neverPreviousNextWhat are you diagnosed with? Binge Eating Bulimia (Disqualification possible due to eating disorder) Anorexia Nervosa OtherPreviousNextSorry, You are not qualified for this treatment!PreviousNextWhat were you diagnosed with?PreviousNextWhat were you diagnosed with? Binge Eating Bulimia (Disqualification possible due to history of eating disorder) Anorexia Nervosa(Disqualified) OtherPreviousNextHow long has it been since you were diagnosed? Less than 12 months ago (Disqualification possible due to history of eating disorder) More than 12 months agoPreviousNextWhat were you diagnosed with?PreviousNext7. Are you currently? Pregnant (Pregnancy is a disqualifier for beginning treatment) Planning to become pregnant (Pregnancy is a disqualifier for beginning treatment) Breastfeeding (Breastfeeding is a disqualifier for beginning treatment) None of the abovePreviousNext8. Do you use recreational drugs? Yes NoPreviousNextWhat drugs do you use? Cocaine (Use of hard drugs is a disqualifier for treatment) Marijuana Methamphetamine (Use of hard drugs is a disqualifier for treatment) OtherPreviousNextWhat drugs do you use?PreviousNext9. How much alcohol do you drink? 3+ drinks per day 1-2 drinks per day 1-2 drinks per week 3-5 drinks per week NonePreviousNext10. Do you suffer from any of these medical conditions? Cardiovascular Disease Fatty liver disease Polycystic ovarian syndrome None of the abovePreviousNextSelect all the conditions that apply to you. Atherosclerosis Atrial fibrillation Arrhythmia History of MI Stents CABG High cholesterol None of the abovePreviousNextDo you have cholesterol greater than 240 or are you on a cholesterol medication? On medication Greater than 240 without medication NeitherPreviousNext11. Did you ever have a fasting triglyceride level above 500? Yes (Fasting triglyceride above 500 is a disqualifier for treatment) NoPreviousNext12. Are you taking high blood pressure medication for Hypertension? Yes NoPreviousNext13. Are you on Warfarin? Yes (Taking Warfarin is a disqualifier for treatment) NoPreviousNext14. Do you have a history of any of the following? Hypothyroidism Hyperthyroidism Graves disease Thyroid nodules NoPreviousNext15. Do you have a personal or family history of thyroid cancer? Yes NoPreviousNextWhat type of thyroid cancer? Medullary Papillary Follicular OtherPreviousNextWhat type of thyroid cancer?PreviousNextDo you have your pathology report? Yes NoPreviousNextPlease upload your pathology report.Choose File PreviousNext16. Do you have a personal history of gallbladder disease? Yes NoPreviousNextDid you have your gallbladder removed? Yes NoPreviousNextWhen did you have your gallbladder removed? Within the last 2 months More than 2 months agoPreviousNext17. Do you have a personal history of acute or chronic pancreatitis? yes NoPreviousNextDid you have your gallbladder removed due to pancreatitis from gallstones? yes NoPreviousNextWhen did you have your gallbladder removed? Within the last 2 months More than 2 months agoPreviousNext18. Do you have a personal or family history of multiple endocrine neoplasia? Yes NoPreviousNext19. Are you diabetic? Yes NoPreviousNextAre you currently taking any of the following medications? Insulin (e.g. Novorapid, Actrapid, Lantus) GLP-1 receptor agonists (exenatide, liraglutide, lixisenatide, dulaglutide, semaglutide, tirzepatide) Clinical protocol discourages taking GLPs to treat diabetes via telemedicine. Patient should receive in-office care to treat diabetes with a GLP-1 medication. Sulfonylureas (e.g. gliclazide, glipizide, glimepiride, tolbutamide) None of the abovePreviousNextDisqualifiedPreviousNextWhat is your hemoglobin A1C? Below 5.7% (Normal) 5.7-6.4% (Prediabetes) Above 6.5% (Diabetes) UnknownPreviousNext20. Are you on CPAP with diagnosed Sleep Apnea? Yes No I am not using a CPAP, but I have been diagnosed with Sleep ApneaPreviousNext21. Have you had bariatric surgery within the last 12 months? Yes NoPreviousNextDisqualifiedPreviousNext22. Have you taken a GLP-1 medication in the past 30 days? Yes Not within 30 days, but previously I have never taken GLPsPreviousNextWhat was your height when you started the GLP-1 medication? (In inches)PreviousNextWhat was your weight when you started the GLP-1 medication? (In pounds) PreviousNextWhich weight loss medication are you currently taking? Semaglutide (Wegovy, Ozempic, Generic) Tirzepatide (Mounjaro, Zepbound, Generic) Liraglutide (Saxenda) Other Weight Loss MedicationPreviousNextWhich weight loss medication are you currently taking? 0.25mg weekly 0.5mg weekly 0.75mg weekly 1mg weekly 1.5mg weekly 1.7mg weekly 2mg weekly 2.5mg weekly OtherPreviousNextWhat was the last dosage you took?PreviousNextDo you have a PDF of your previous script, or a picture of your current vial? Yes NoPreviousNext Please upload your script or a picture of your current vial.Choose File PreviousNextWhat was the last dosage you took? 2.5mg weekly 5mg weekly 7.5mg weekly 10mg weekly 12.5mg weekly 15mg weekly OtherPreviousNextWhat was the last dosage you took?PreviousNextDo you have a PDF of your previous script, or a picture of your current vial? Yes NoPreviousNext Please upload your script or a picture of your current vial.Script/Photo PreviousNextHow long have you been taking the medication consecutively? One Month Two Months Three Months Four Months Five Months Six Months More than Six MonthsPreviousNext How long have you been on your current dose? Less than one month One Month Two Months Three Months Four Months Five Months Six Months More than Six MonthsPreviousNextWould you like to move up to the next dose (increase monthly according to regular schedule) or maintain your current dose monthly? Increase dose monthly according to regular schedule Increase dose this month and then maintain that dose monthly Decrease dose this month and then maintain that dose monthly Maintain your current dose monthly OtherPreviousNextCall Us: 123 456 789PreviousNextHave you been taking the medication as prescribed? Yes NoPreviousNextPlease explain how you have deviated from the dosing instructions. PreviousNextHave you experienced any of the following side effects? Nausea Vomiting Diarrhea Constipation Reduced Appetite Depression Suicidal thoughts Hair loss No side effects OtherPreviousNextHow effective do you feel the medication has been in managing your weight? Very Effective Somewhat Effective Not EffectivePreviousNextHow long has it been since you stopped taking your GLP medication? 2-5 months 6-9 months 10-11 months 12+ monthsPreviousNextWhat was your height when you started the GLP-1 medication? (In inches)PreviousNextWhat was your weight when you started the GLP-1 medication? (In pounds) PreviousNextWhat GLP medication have you previously taken? Semaglutide (Wegovy, Ozempic, Generic) Tirzepatide (Mounjaro, Zepbound, Generic) Liraglutide (Saxenda) Other Weight Loss MedicationPreviousNextWhat was the last dosage you took? 0.25mg weekly 0.5mg weekly 0.75mg weekly 1mg weekly 1.5mg weekly 1.7mg weekly 2mg weekly 2.5mg weekly OtherPreviousNextWhat was the last dosage you took?PreviousNextDo you have a PDF of your previous script, or a picture of your current vial? Yes NoPreviousNextPlease upload your script or a picture of your current vial.Script/Photo PreviousNextWhat was the last dosage you took? 2.5mg weekly 5mg weekly 7.5mg weekly 10mg weekly 12.5mg weekly 15mg weekly OtherPreviousNextWhat was the last dosage you took?PreviousNextDo you have a PDF of your previous script, or a picture of your current vial? Yes NoPreviousNext Please upload your script or a picture of your current vial.Script/photo PreviousNextDid you experience any of the following side effects? Nausea Vomiting Diarrhea Constipation Reduced Appetite Depression Suicidal thoughts Hair loss None of the above OtherPreviousNextHow effective do you feel the medication has been in managing your weight? Very Effective Somewhat Effective Not EffectivePreviousNext23. Depending on state regulations, your provider may reach out to you to perform a consultation over the phone. Otherwise, your provider will review your intake forms and approve your script if all criteria are met. I understand that my provider will only reach out via phone call if they think it is necessary to get more information from me. I do not need to speak to the provider. I would like to speak to the provider. Previous Continue
