Weight Loss Program─ Confidential

Tirzepatide Intake Questionnaire

A short medical screening so Dr. Colon can confirm Tirzepatide is right for you. Your responses are confidential and reviewed before we contact you.

Section I

Personal Information

Section II

Medical Screening

Review these questions with your healthcare provider. Your responses are confidential and reviewed personally by Dr. Colon.

  1. 1.

    Have you or any of your family members ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC)?

  2. 2.

    Do you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?

  3. 3.

    Are you allergic to Tirzepatide or any of its ingredients?

  4. 4.

    Have you ever had inflammation of the pancreas (pancreatitis), and has it been determined whether Tirzepatide is safe for such cases?

  5. 5.

    Do you have type 1 diabetes, for which Tirzepatide is not recommended?

  6. 6.

    Are you under 18 years old?

  7. 7.

    Do you have other medical conditions, including problems with your pancreas or kidneys, or severe problems with your stomach, such as slowed emptying of your stomach (gastroparesis) or problems digesting food?

  8. 8.

    Do you take other diabetes medicines, such as insulin or sulfonylureas?

  9. 9.

    Do you have a history of diabetic retinopathy?

  10. 10.

    Are you scheduled to have surgery or other procedures that use anesthesia or deep sleepiness (deep sedation)?

  11. 11.

    Are you pregnant, plan to become pregnant, breastfeeding, or plan to breastfeed? It is not known if Tirzepatide will harm your unborn baby or pass into your breast milk.

  12. 12.

    Do you take any other prescription medicines or over-the-counter drugs, vitamins, or herbal supplements?

  13. 13.

    Are you allergic to Zofran (Ondansetron)?

Dr. Colon will review your responses and follow up within one business day.