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GLP Injection Medical Intake
Name
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Today's Date
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Date of Birth
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August 2026
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Phone number
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Home address
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Email
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Please state your Emergency contact's name, relationship, and phone number
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Preferred contact method
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Phone
Text
Email
How did you hear about us?
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Google
Chat GPT or other AI engine
Yelp
Instagram
Friend
current client
seminar
physician referral
Panteha Partovi, PA-C
Other
What is your main goal?
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Weight Loss/Management
PCOS management
Anti-Aging
Pre/Menopausal symptom mgmt
Other
If your main goal is weight loss, what have you tried in the past?
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Have you used Ozempic, Wegovy, Mounjaro, or Zepbound before?
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required
Yes
No
Which GLPs have you used in the past?
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required
Ozempic ( Brand Semaglutide)
Zepbound ( Brand Tirzepatide)
Mounjaro ( Brand Tirzepatide)
Semaglutide ( Generic compound)
Tirzepatide ( Generic Compound)
Retatrutide
Other
None
What is your current Height?
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What is your current weight?
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Do you drink Alcohol? If yes, please state average drinks per week.
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Do you use Tobacco or Marijuana?
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required
Yes
No
Sometimes
History of
Please provide a list of the medications that you are currently taking. If none, state N/A
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Please provide a list of the Vitamins and Supplements that you are currently taking. If none, state N/A
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Do you have any drug allergies or Sensitivities? If none state N/A
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Have you had any surgeries? If none, please state N/A.
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Do you have any of the following? (select all that apply)
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Overweight (BMI 25-29)
Obesity (BMI over 30)
Type 1 Diabetes
Type 2 Diabetes
Hypertension
High Cholesterol
PCOS
Endometriosis or other hormonal conditions
Perimenopause/Menopause
Breastfeeding, Pregnant or planning to conceive ( within the next 3 months)
Personal or family History of medullary thyroid carcinoma (MTC) thyroid cancer
Personal or family History of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
Ulcerative Colitis or Crohn’s disease
Severe gastroparesis (delayed stomach emptying) or other severe GI issues
Gallbladder Disease
History of pancreatitis
High Blood Calcium Levels
Current or History of Eating disorders
Current or History of Mood Disorders
Recent weight gain
Emotional eating or sugar cravings
Insomnia or other Sleep disorders
Please list any medical condition that was not mentioned above. If none, state N/A
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Please give us a current snapshot of your lifestyle including Diet, Exercise, Sleep quality and Stress levels
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Upload complete labs from the last 12 months or email them to info@santoshaaesthetics.com. If N/A we use Quest Diagnostics to order neccesary Labs
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If you have health insurance, upload front and back of card here.
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I understand this is a medical weight loss program and does not guarantee results. I agree to be contacted for scheduling and follow-up
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Do you have medical insurance? If so, please let us know and if we need to order labs; they may be covered by your carrier.
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