Slimming Clinic questionnaire – MyGeneHub

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Slimming Clinic Test questionnaire

Client Questionnaire for :
Mounjaro/Ozempic/Wegovy Treatment

Please fill in the following questionnaire so we can match you to a clinician who can authorise treatment

Personal Information

Name *

Date of Birth *

Gender *

Contact *

Email *

Emergency Contact Name *

Address *

Medical History

Do you have diabetes? *

Have you ever been diagnosed with any of the following conditions? (Check all that apply)Gastrointestinal disorders (e.g., gastroparesis)PancreatitisThyroid disorders (e.g., medullary thyroid carcinoma)Kidney diseaseLiver diseaseCancerOther

Others? (please specify):

Please list any other medical conditions you have:

Are you currently taking any medications? If yes, please list them:

Have you had any allergic reactions to medications? If yes, please specify:

Have you experienced any of the following symptoms? (Check all that apply)Severe allergic reactionsHypoglycemia (low blood sugar)Diabetic ketoacidosisEye problems related to diabetes

Others? (please specify):

Lifestyle and Weight History

What is your current weight?

What is your height?

Do you follow a specific diet? If yes, please describe:

Have you tried other weight loss methods? (Check all that apply)DietingExercise programsPrescription medicationsWeight loss surgery

Others? (please specify):

Do you engage in regular physical activity? If yes, please describe:

Contraindications

Have you or your family members been diagnosed with medullary thyroid carcinoma?

Do you have multiple endocrine neoplasia syndrome type 2 (MEN 2)?

Have you been diagnosed with severe gastrointestinal disease or obstruction?

Have you had a history of pancreatitis?

Are you currently pregnant or planning to become pregnant?

Are you breastfeeding?

Consent *

I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that incorrect or withheld information may affect my treatment.

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English

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Our Vision
DNA & YOU
Tests
GET STARTED
FAQs
- NUTRIFIT PREMIUM FAQs
- NUTRIFIT CLASSIC FAQs
Buy Now
CONTACTS
English
- Arabic
- Portuguese

English

Arabic

Portuguese