GLP-1 Follow-up Form - City Life Pharmacy

Over the past 4 weeks, approximately how many pounds have you lost?

What is your current weight in pounds?

In the last 3 months have you experienced any adverse or allergic reactions to semaglutide/tirzepatide?

Yes

No

Do you have any new changes / additions to your medical history?

Yes

No

Do you have any additions or changes to your medications?

Yes

No

What current weight loss medication are you currently taking?

Please select what you would like to do with this next dose?

Continue with the same dose

Increase the dose

Decrease the dose

Do you have any questions for your health care provider?

Yes

No