SEMAGLUTIDE MEDICAL ASSESSMENT FORM - Skinly Aesthetics

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Semaglutide assessment form

Step 1 of 10

10%

Name(Required)

First Last

Date of Birth(Required)

Sex(Required)

Male

Female

Phone Number(Required)

Email Address(Required)

Are you here to be evaluated for weight loss?(Required)

Yes

No

Do you have any of the following medical problems?(Required)

Cirrhosis/liver disease

End stage renal failure

None of the above

Do you have any of the following medical problems?(Required)

High cholesterol

Obstructive sleep apnea

Type 1 diabetes

Type 2 diabetes

Ha1C above 5.7

None of the above

Have you ever attempted to lose weight through a weight management program longer than 6 months?(Required)

Yes

No

Are you willing to reduce your caloric intake alongside medication?(Required)

Yes

No

Are you willing to increase your physical activity alongside medication?(Required)

Yes

No

Have you ever dealt with following:(Required)

Anorexia nervosa

Bulimia nervosa

None of the above

Do you have any of the following?(Required)

History of chronic pancreatitis or previous episode of pancreatitis due to GLP-1

History of severe gastrointestinal disease

History of diabetic retinopathy or other retinopathy

History of medullary thyroid cancer

History of Bariatric surgery within past 6 months

History of MEN-2 (multiple endocrine neoplasia type 2)

History of gallbladder disease (excluding history of gallbladder removal/cholecystectomy)

Diabetes

None of the above

Does anyone in your Family have a history of:(Required)

MEN-2 (multiple endocrine neoplasia type 2)

Medullary thyroid cancer

None of the above

Are you taking any medications?(Required)

Yes

No

Current Medications:(Required)

Please list the generic name of your medication, the dose, how many times per day, how long you have been on this medication.

Did you ever have any type of thyroid cancer?(Required)

Yes

No

Please type the thyroid cancer type/s you have or had?(Required)

Do you have any allergies to medications?(Required)

Yes

No

List your medication allergies(Required)

What is your goal weight?(Required)

Current Weight (lb)(Required)

Height(Required)

Disclaimer(Required)

According to the American Board of Obesity Medicine (ABOM) patients who have a BMI between 27-30 may qualify for medical assisted weight loss based on other medical conditions they may have. Patients below BMI of 27 are not ABOM candidates.
Link to BMI calculator: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
If your prescribing doctor doesn’t feel you qualify, support will provide you a refund within 4 business days.

I Agree

Please provide a recent blood pressure measurement within the last 6 months, which should be listed as follows: Systolic (top number)/Diastolic (bottom number)(Required)

If you are not sure, please go have your blood pressure obtained (typically free at your local pharmacy).

Are you pregnant or expecting to be?(Required)

Pregnant

Breastfeeding or lactating

Expecting to be pregnant

No or Doesn’t apply

Where do you live?

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Photo of Your Drivers License(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.

Your photo in active wear or swimsuit(Required)

Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.

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Explore treatment options tailored just for you. Schedule your consultation right now.

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Visit Us

UPPER EAST SIDE

Phone: 212-774-4264 157 East 64th Street, 2nd floor New York, New York 10065 Email: info@skinlyaesthetics.com

@skinlyaesthetics

UPPER EAST SIDE

157 East 64th Street, 2nd floor New York, New York 10065
212-774-4264
info@skinlyaesthetics.com

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HOME
About us
- About us
- Press
Before & After
- Body
- Face
  - Injectables
  - Advanced /Non-Surgical
Face
- Botox
  - Crow’s Feet
  - Eyebrow Lift
  - Masseter
  - Chin
  - Lip Flip
  - Baby Botox
  - Neck-Tox
  - Trap-Tox
  - DAO Botox
  - TMJ Botox
  - Hyperhidrosis
  - Types of Toxin
    - Botox
    - Dysport
- Fillers
- Non-Surgical
  - PDO Thread
  - Endolift
  - Ellacor
  - Ultherapy
  - Upneeq
- Lasers
- Microneedling
  - RF Microneedling
  - Mechanical
    - DermaPen
    - AquaGold
- Biostimulators
- Filler Dissolving
  - Hyaluronidase
- Kybella
Body
Weight Loss
Wellness
Blog
Shop
Consult

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