EnvRx

Patient Intake Form

Treatment

Treatment are you requesting?

Tirzepatide

Have you ever had an adverse or allergic reaction to Tirzepatide, or to any of its ingredients: Have you ever had an adverse or allergic reaction to another GLP-1 receptor agonist such as, but without limitation to, Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin) Have you taken or are you currently taking any of the following medications- Semaglutide (Ozempic/Wegovy), Tirzepatide (Mounjaro/Zepbound), Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin)?

which ones and what dose?

Do you have a personal medical history involving any of the following medical conditions?

Diabetes Mellitus

Which type?

Diabetic Retinopathy Diabetic Ketoacidosis Pancreatitis Gallbladder Disease Medullary Thyroid Carcinoma Multiple Endocrine Neoplasia Kidney disease/kidney insufficiency or transplant/Acute Kidney Injury Stomach Problems Bariatric Surgery or other GI Surgery Liver Disease/Cirrhosis Leber Hereditary Optic Neuropathy Are you Pregnant Are you currently experiencing, or have you experienced, depression with a history of suicidal attempts, suicidal thoughts, or suicidal ideation Do you have any family history of Multiple Endocrine Neoplasia, Type 2, (MEN 2) or Medullary Thyroid Carcinoma (MTC) Are you currently receiving Chemotherapy

Are you taking any of the following medications

Abiraterone Acetate Somatrogon-GHLA Chloroquine Flouroquinolones Hydroxychloroquine Insulin Insulin Secretagogues GLP-1s

Semaglutide

Have you ever had an adverse or allergic reaction to Semaglutide, or to any of its ingredients: Have you ever had an adverse or allergic reaction to another GLP-1 receptor agonist such as, but without limitation to, Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin) Have you taken or are you currently taking any of the following medications- Semaglutide (Ozempic/Wegovy), Tirzepatide (Mounjaro/Zepbound), Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin)?

which ones and what dose?

Do you have a personal medical history involving any of the following medical conditions?

Diabetes Mellitus

Which type?

Diabetic Retinopathy Diabetic Ketoacidosis Pancreatitis Gallbladder Disease Medullary Thyroid Carcinoma Multiple Endocrine Neoplasia Kidney disease/kidney insufficiency or transplant/Acute Kidney Injury Stomach Problems Bariatric Surgery or other GI Surgery Liver Disease/Cirrhosis Leber Hereditary Optic Neuropathy Are you Pregnant Are you currently experiencing, or have you experienced, depression with a history of suicidal attempts, suicidal thoughts, or suicidal ideation Do you have any family history of Multiple Endocrine Neoplasia, Type 2, (MEN 2) or Medullary Thyroid Carcinoma (MTC) Are you currently receiving Chemotherapy

Are you taking any of the following medications

Abiraterone Acetate Somatrogon-GHLA Chloroquine Flouroquinolones Hydroxychloroquine Insulin Insulin Secretagogues GLP-1s

SORRY YOU DO NOT QUALIFY

Lifestyle Info

Do you Smoke: Do you Drink: Caffeine:

# of Cups/Cans Per Day:

Do you Exercise: Are you dieting:

Are you on a physician prescribed medical diet?

Personal Medical History

Acid Reflux GERD: Yes No Unknown

Acne: Yes No Unknown

Arthritis: Yes No Unknown

Asthma: Yes No Unknown

Afib: Yes No Unknown

Autoimmune: Yes No Unknown

Bleeding Disorders: Yes No Unknown

Cancer: Yes No Unknown

Congestive Heart Failure: Yes No Unknown

COPD: Yes No Unknown

Coronary Artery Disease: Yes No Unknown

Chronic Fatigue Syndrome: Yes No Unknown

Crohn's Disease: Yes No Unknown

Dementia: Yes No Unknown

Depression: Yes No Unknown

Diabetes: Yes No Unknown

Difficulty Urinating: Yes No Unknown

Eczema: Yes No Unknown

Epstein Barr Virus: Yes No Unknown

Fever Chills: Yes No Unknown

Fibromyalgia: Yes No Unknown

Gastrointestinal Disorders: Yes No Unknown

Glaucoma: Yes No Unknown

Heart Disease/Heart Attack: Yes No Unknown

have you had stents or open heart?

Hemachromatosis: Yes No Unknown

Hepatitis: Yes No Unknown

Hernia: Yes No Unknown

Hives: Yes No Unknown

High Blood Pressure: Yes No Unknown

High Cholesterol: Yes No Unknown

HIV: Yes No Unknown

Hyperthyroidism: Yes No Unknown

Hypothyroidism: Yes No Unknown

Irritable Bowel Syndrome: Yes No Unknown

Kidney Disease: Yes No Unknown

Liver Disease: Yes No Unknown

Lung Problems: Yes No Unknown

Lupus: Yes No Unknown

Migraines: Yes No Unknown

Mononucleosis: Yes No Unknown

Multiple Sclerosis: Yes No Unknown

Nasal Polyps: Yes No Unknown

Overweight: Yes No Unknown

Parathyroid: Yes No Unknown

Psoriasis: Yes No Unknown

Psychiatric Disorders: Yes No Unknown

Rosacea: Yes No Unknown

Sarcoidosis: Yes No Unknown

Seizures: Yes No Unknown

Sickle Cell Anemia: Yes No Unknown

Sleep Apnea: Yes No Unknown

Staph Skin Infection: Yes No Unknown

Stroke: Yes No Unknown

Thrombophlebitis: Yes No Unknown

Ulcerative Colitis: Yes No Unknown

Underweight: Yes No Unknown

Vitiligo: Yes No Unknown

Other: Yes No Unknown

Family Medical History

Alcohol Abuse: Yes No Unknown

Aneurysm: Yes No Unknown

Arthritis: Yes No Unknown

Asthma: Yes No Unknown

Autoimmune: Yes No Unknown

Birth Defects: Yes No Unknown

Blood Clotting: Yes No Unknown

Cancer: Yes No Unknown

What type of cancer?

COPD: Yes No Unknown

Deep Vein Thrombosis: Yes No Unknown

Dementia: Yes No Unknown

Depression: Yes No Unknown

Diabetes: Yes No Unknown

Eye Disease: Yes No Unknown

Heart Attack: Yes No Unknown

Heart Disease: Yes No Unknown

Hemochromatosis: Yes No Unknown

High Blood Pressure: Yes No Unknown

High Cholesterol: Yes No Unknown

Kidney Disease: Yes No Unknown

Liver Disease: Yes No Unknown

Lung Disease: Yes No Unknown

Osteoporosis: Yes No Unknown

Psychiatric Disorders: Yes No Unknown

Stroke: Yes No Unknown

Thyroid Disease: Yes No Unknown

Ulcers: Yes No Unknown

Health Record

Leave blank if None Apply

Medical Conditions

Condition: Comment: Date Of Onset:

Drug Allergies

Drug Name: Reaction:

Patient Allergies

Name: Reaction:

Surgeries

Surgery: Comment: Date Of Surgery:

Medications

Name: Comment: