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Which provider
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Reason for visit
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Goal Weight
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Waist Circumference
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BMI/FAT %
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Heart
• • •
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Others please specify
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Lungs
• • •
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Others please specify
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Neck
• • •
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Others please specify
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Pupils
• • •
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Others please specify
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DX
• • •
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Others please specify
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GYN (if applicable)
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LMP
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Birth Control
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Lab Works - Redraw Labs
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Panel
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Date
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Allergies
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Do you have the history of the following
• • •
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Do you experience any of the following
• • •
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Do you have the history of the following
• • •
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Reproductive Cancer
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If yes, please specify
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Do you or have you smoked, used nicotine patches, or use street drugs?
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If yes what
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How much per day
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Do you drink alcohol?
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If yes how often
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How much do you consume
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Notes
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Orders
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Patient is a candidate for the hCG/Lifestyle program
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Patient is a candidate for the Semaglutide/Lifestyle program
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Patient is a candidate for the Tirzepatide/Lifestyle program
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Patient is a candidate for the Peptide/ Lifestyle program
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Patient is a candidate for the hCG program only
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Patient is a candidate for the Peptide program only
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Patient is a candidate for the Semaglutide program only
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Patient is a candidate for the Tirzepatide program only
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Patient is a candidate for the Lifestyle program only
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Patient is a candidate for the HRT program
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Side effects and adverse effects of hCG discussed with patient and handout given
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Side effects and adverse effects of peptides discussed with patient and handout given
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side effects and adverse effect semaglutide/ tirzepatide
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side effects and adverse effect HRT
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Phendimetrazine 35 mg PO ½ tab-1 tab daily-bid prn breakthrough hunger while on hCG
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Phentermine_____mg PO1/2 tab-1
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tab daily x _____ days
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Side effects and adverse effects of appetite suppressants discussed and handout given
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Signs and symptoms of Serotonin Syndrome discussed and handout given
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Hctz (Water Pill)
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Potassium gluconate 595 mg PO one tablet 2 times per week prn leg cramps
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Lipotropic injections 1 mL IM per program protocol
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Vitamin B-12 1 mL IM per program protocol
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Patient is cleared to take these vitamin injections
• • •
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Patient is cleared to take these peptides
• • •
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Pt was informed about the possible negative effects of taking the hCG, Phendimetrazine
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Pt was instructed to stop taking the hCG, Phendimetrazine, or Phentermine immediately
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Getting Medication w/ HCG or Sermorelin
• • •
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NOT DOING HCG or SERMORELIN MEDS ONLY
• • •
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HOW MANY PILLS dispensed
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HOW MANY PILLS dispensed
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Lot #
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Lot #
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Others
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Provider Name
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Provider Signature
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Patient Signature
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NOTHING DONT PUT HERE
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Patient is a candidate for the Peptide/ Lifestyle program
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