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SEMAGLUTIDE QUESTIONNAIRE
First Name
*
Last Name
*
Phone Number
*
Email
*
Do you have a body mass index (BMI) of 30 or higher?
Yes
No
I don't know
Do you have a BMI of 27 or higher with at least one weight-related health condition such as high blood pressure or Type 2 diabetes?
Yes
No
I'm unsure
Have you tried other weight loss methods such as diet and exercise without success?
Yes
No
Are you willing to inject yourself with medication once a week to aid in weight loss?
Yes
No
Are you committed to making lifestyle changes, such as eating a healthy diet and exercising regularly, in conjunction with taking Semaglutide?
Yes
No
Do you have a history of pancreatitis?
Yes
No
Do you have a history of thyroid cancer?
Yes
No
Are you pregnant or planning to become pregnant in the near future?
Yes
No
Are you breastfeeding?
Yes
No
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