Follow Up Appointments – MP Weight Loss Clinic

Name

This field is for validation purposes and should be left unchanged.

Patient Information

Confirm the patient identity before reviewing GLP-1 progress.

This follow-up form usually takes 3–5 minutes.
Please answer as best you can. If you are unsure, choose “Not sure” or leave optional items blank and our staff will review it with you.

Patient First Name(Required)

Patient Last Name(Required)

Date of Birth(Required)

Used to match this follow-up to the correct patient chart.

Phone Number(Required)

Email Address(Required)

Who Completed This Form?(Required)

Preferred Contact Method(Required)

Text Message Opt-In(Required)

Yes, I agree to receive text messages

Do you agree to receive appointment, refill, and follow-up text messages from MP Weight Loss? Message and data rates may apply. Reply STOP to opt out.

Progress & Measurements

Weight fields are number fields so patients can type the value instead of scrolling a long dropdown.

Height(Required)

Feet Inches

Current Weight (lbs)(Required)

Please enter a number from 50 to 700.

Enter your current weight in pounds (lbs). Please weigh yourself before completing this form and do not estimate.

Goal Weight (lbs)

Please enter a number from 50 to 700.

Optional, if known.

Which medication are you taking?(Required)

Semaglutide

Tirzepatide

How many units of Semaglutide are you taking a week?(Required)

Semaglutide - Other # of Units(Required)

Please enter a number from 50 to 700.

Optional, if known.

Semaglutide: Other # of Units(Required)

Please enter a number from 0 to 100.

How many units of Tirzepatide are you taking a week?(Required)

Tirzepatide: Other # of Units(Required)

Please enter a number from 0 to 50.

Goal Weight (lbs)(Required)

Please enter a number from 50 to 700.

Optional, if known.

Do you split your dose?(Required)

Yes

Microdosing is 1 shot every 3.5 - 4 days and splitting the dose. This will equal 1 full dose per week.

Which day do you take your shot?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

If you split your dose... which days do you take them?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Microdosing is 1 shot every 3.5 - 4 days and splitting the dose.

Shot 1

Shot 2

How many weeks have you been on the current dose?

Please enter a number from 0 to 104.

Last Injection Date

Where do you usually inject your GLP-1 medication?(Required)

Any Missed or Delayed Injections Since Last Visit?

Yes

Not sure

Missed or Delayed Dose Details

Enter approximate date(s) and what happened, if applicable.

Side Effects & Safety Check

This helps identify common side effects and symptoms that may require provider review.

This form is not for emergencies.
If you have chest pain, trouble breathing, severe or persistent abdominal pain, persistent vomiting, severe allergic reaction, signs of dehydration, or cannot keep fluids down, seek urgent/emergency care or call 911.

Since your last visit, how has everything been going?(Required)

Everything is going well

Mostly okay, but I have a few concerns

I am having problems or need provider help

I am not sure

This helps us prioritize your follow-up and keeps the form easier for patients who are doing well.

Are you noticing any abdominal pain?(Required)

Yes

Describe your abominal pain(Required)

Side Effects Since Last Visit(Required)

None

Nausea

Vomiting

Diarrhea

Constipation

Heartburn / reflux

Fatigue

Headache

Dizziness / lightheadedness

Injection site reaction

Other

Safety / Red Flag Symptoms(Required)

None

Severe or persistent abdominal pain

Persistent vomiting or unable to keep fluids down

Chest pain or shortness of breath

Signs of dehydration

Yellowing of skin or eyes

Severe allergic reaction

New or worsening mood concerns

Pregnancy or positive pregnancy test

Select any that apply. If severe symptoms are present, seek urgent medical care.

Overall Side Effect Severity(Required)

None

Mild

Moderate

Severe

Side Effect or Safety Details(Required)

Explain any symptoms, timing, severity, or concerns.

Describe your appetite suppression (Food Noise)

0 = no appetite control, 10 = excellent appetite control.

Bowel Movement Frequency(Required)

Average Daily Water Intake(Required)

How many calories are you consuming a day?(Required)

Estimated Protein Intake (grams/day)(Required)

Exercise Days Per Week(Required)

Please enter a number from 0 to 7.

Range 0-7

Describe your exercise plan.(Required)

Refills, Dose Concerns & Treatment Plan

Provide refill timing and any questions for the provider.

Do you need a new prescription called in?(Required)

Yes

Not sure

How soon do you think you will run out?

This is easier than guessing whether a refill is needed.

Pharmacy Fulfillment Preference

Will the Shipping Address Be Different From the Address on File?(Required)

No, use the address on file

Yes, ship to a different address

Answer this only if you selected shipping.

Shipping Recipient Name

Shipping Address Line 1

Shipping Address Line 2

Shipping City

Shipping State

Shipping ZIP Code

Dose Discussion Requested(Required)

No dose change requested

Discuss increasing dose if appropriate

Discuss lowering dose due to side effects

Discuss staying at current dose

Discuss medication options

Any Medication Changes Since Last Visit?

Yes

Not sure

Include prescription, over-the-counter, diabetes, blood pressure, nausea, constipation, or supplement changes.

Medical Updates Since Last Visit

None

New medication started

ER visit or hospitalization

Surgery scheduled or completed

New diagnosis

Pregnancy / breastfeeding update

Other

Medication Change Details

List medication name, dose if known, when it changed, and why.

Questions for the Provider

Add anything you want reviewed during your follow-up.

Before you submit:
Our staff/provider will review your answers. Refills and dose changes are not automatic and may require follow-up.

Patient Acknowledgment(Required)

I understand refill requests and dose changes require provider review and are not guaranteed from this form submission alone.

Before you submit(Required)

Confirm: I have reviewed all information provided in this form and certify that it is accurate and complete to the best of my knowledge.