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Follow Up Appointment Form
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GLP-1 Enhanced Follow-Up Form
Enhanced follow-up form for GLP-1 weight loss patients.
1
Patient Information
2
Progress & Measurements
3
Side Effects & Safety
4
Refills & Plan
Phone
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)
MM slash DD slash YYYY
Used to match this follow-up to the correct patient chart.
Phone Number
(Required)
Email Address
(Required)
Who Completed This Form?
(Required)
Select one
Patient
Clinic staff
Caregiver / family member
Other
Preferred Contact Method
(Required)
Select one
Phone call
Text message
Email
Patient portal
Text Message Opt-In
(Required)
Yes, I agree to receive text messages
No
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.
Clinic Start Weight (lbs)
Please enter a number from
50
to
700
.
Optional. Leave blank if you are unsure — the clinic can confirm this from your chart.
Current Weight (lbs)
(Required)
Please enter a number from
50
to
700
.
Enter today’s current weight in pounds.
Goal Weight (lbs)
Please enter a number from
50
to
700
.
Optional, if known.
Waist Circumference (inches)
Please enter a number from
10
to
100
.
Current Medication
(Required)
Select medication
Semaglutide
Tirzepatide
Other
Not sure
How many units of Tirzepatide are you taking a week?
(Required)
10
25
40
60
80
96
100
other
How many units of Semaglutide are you taking a week?
(Required)
8
10
17
20
25
33
42
50
other
If you split your dose... which days do you take them?
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
MM slash DD slash YYYY
Most Recent Injection Site
Select site
Abdomen
Thigh
Upper arm
Other
Not sure
Any Missed or Delayed Injections Since Last Visit?
No
Yes
Not sure
Missed 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?
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.
Side Effects Since Last Visit
(Required)
None
Abdominal Pain
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
None
Mild
Moderate
Severe
Side Effect or Safety Details
(Required)
Explain any symptoms, timing, severity, or concerns.
Appetite Control
Rate 0–10
0
1
2
3
4
5
6
7
8
9
10
0 = no appetite control, 10 = excellent appetite control.
Cravings Control
Rate 0–10
0
1
2
3
4
5
6
7
8
9
10
0 = no craving control, 10 = excellent craving control.
Bowel Movement Frequency
Select frequency
Daily
Every 2 days
Every 3 or more days
Constipation concern
Prefer not to answer
Average Daily Water Intake
Select range
Less than 40 oz/day
40–64 oz/day
65–90 oz/day
More than 90 oz/day
Not sure
Estimated Protein Intake (grams/day)
Please enter a number from
0
to
300
.
Optional estimate.
Exercise Days Per Week
(Required)
Please enter a number from
0
to
7
.
Refills, Dose Concerns & Treatment Plan
Provide refill timing and any questions for the provider.
Do you need a new prescription called in?
Yes
No
Not sure
How soon do you think you will run out?
Select timing
Already out
Less than 1 week
1–2 weeks
More than 2 weeks
Not sure
This is easier than guessing whether a refill is needed.
Pharmacy Fulfillment Preference
Select preference
Ship to Patient
Ship to Clinic
Not sure
How should the pharmacy handle this refill, if a refill is approved?
Will the Shipping Address Be Different From the Address on File?
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
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?
No
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.
Δ
GLP-1
GLP-1 + GIP
Phentermine
Request an appointment
Weight Loss
Appointments
Pricing
Tools
BMI Calculator
Daily Goals
How to inject
Lucy, Ai Weight Loss Coach
Shot Tracker
Online Forms
New Patients
New Patient Form
Consent Form
Request an Appointment
Current Patients
Follow Up Appointments
Restart Injections
Shot Tracker
Shot Tracker
Shot History
