First Name | Wesley |
Last Name | Phillips |
Date of Birth | 01/28/1987 |
Phone Number | 5039293446 |
wesphillips.pa@gmail.com | |
Address | 3733 Southeast 69th Avenue |
City | Portland |
State | OR |
Zip | 97206 |
Sex | Male |
Self-reported Meds | Meloxicam |
Allergies | Tree nuts, carrots, fish |
Medical Conditions | None |
Patient preference |
Name:
Pharmacyhub Semaglutide starter (3
month)
quantity:
2.5
strength:
2.5mg/ml
refills:
0
MedId:
0iNQ4Bzjla0nFd9e1rCtBTpax40lsIWd
Name:
GLP-1 Injection Kit 1 ml syringe -
Quarterly - Pharmacy Hub
quantity:
1
strength:
None provided
refills:
0
MedId:
bcA8LzvVTABsJGWA74EBtS4j7iFplvA1
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Consents for telemedicine and privacy policy signed? | true |
Are you currently taking a GLP-1 Medication? |
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Do you have a recent prescription (within the last
two months) for a GLP-1 medication such as Ozempic,
Wegovy, Zepbound, Mounjaro, Semaglutide, or
Tirzepatide? |
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Which medication are you prescribed? |
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Which dosage of your prescribed medication most
closely matches your most recent dosage? |
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Do you have any side effects at your current dosage? (Leave blank if none) |
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How would you like to continue your treatment?
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What is your Height? |
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What is your current weight in lbs? |
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What is your BMI? |
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Do you currently or have you ever had any of the
following conditions or procedures? Gastroparesis.
Inflammatory bowel disease. Pancreatitis. Pancreatic
cancer. Advanced Kidney disease. Insulin-dependent
diabetes. Thyroid cancer. Family history of thyroid
cancer. Family history of MEN-2 syndrome. PCOS with
fertility problems. Eating disorder, past or
present. Suicidal thoughts in the past 12 months.
Anorexia or bulimia. Gastric bypass in the past 6
months. |
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Do you currently or have you ever had Gallbladder
disease? |
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Do you currently or have you ever had
Hypertriglyceridemia (elevated triglycerides)?
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Are you allergic to any of the following:
Semaglutide (Ozempic / Wegovy), Tirzepatide
(Mounjaro / Zepbound), or Liraglutide (Saxenda)?
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Do you take any of the following medications?
Insulin, Glimepiride (Amaryl), Glipizide (Glucotrol
and Glucotrol XL), Glyburide (Micronase, Glynase,
and Diabeta), Sitagliptin, Saxagliptin, Linagliptin,
Alogliptin |
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What other information or questions do you have for the doctor? |
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Do you confirm you are the patient and attest that
the information provided is true to best of your
knowledge? I verify that I am the patient and have
completed the intake form and acknowledge the
following. I have reviewed, understand, and attest
that the information I have provided above is true
to best of my knowledge. I understand that it is
critical to my health to share complete health
information with my doctor. I will not hold the
doctor or affiliated medical practice responsible
for any oversights or omissions, whether intentional
or not in the information that I provided above.
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Do you acknowledge the general guidelines for the
product, off-label use and it’s side effects? The
traditional use of weight loss medications is for
individuals with a BMI of 30 and above or to those
who are overweight who have associated health
conditions. Using it for someone in the BMI range
(27-29) without an accompanying health condition is
termed "off-label." Using a medication "off-label"
refers to the practice of prescribing a drug for a
purpose, age group, dosage, or form of
administration that is not included in the approved
labelling by regulatory agencies like the U.S Food
and Drug administration (FDA). While a medication
undergoes rigorous testing for specific uses before
receiving approval, healthcare providers may
discover through clinical experience or research
that it can be effective for treating other
conditions. There may be benefits such as weight
reduction for individuals within your range. If you
agree to this off label use, it's crucial to follow
the prescribed regimen and report any concerns.
Please discuss any questions with us. |
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