Patient Qualifier Assessment Form

Have you ever used GLP-1 medications in the past?

Yes No

If yes, which GLP-1 medication(s) have you used?

Semaglutide (Ozempic®, Wegovy®, Rybelsus®) Tirzepatide (Mounjaro®, Zepbound®) Liraglutide (Saxenda®, Victoza®) Dulaglutide (Trulicity®) Exenatide (Byetta®, Bydureon®) Other:

How long did you use it?

<1 month 1–3 months 3–6 months 6–12 months >1 year

What was your typical dosage or titration level (if known)?

Did you experience any side effects?

Nausea Vomiting Constipation Diarrhea Fatigue Headache Other:

Did you experience beneficial effects?

Weight loss Appetite control Improved blood sugar Other:

Why did you stop or change medications?

Cost Side effects No longer prescribed Lost access to provider Other:

Would you like to restart a GLP-1 medication?

Yes No Unsure – would like to discuss with provider

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Patient Weight Loss & Peptide Prescription Questionnaire

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Patient Qualifier Assessment Form

Ready to Begin ? Take the First Step!

Patient Weight Loss & Peptide Prescription Questionnaire

Ready to Begin ?
Take the First Step!