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Semaglutide Patient Questionnaire
Please fill out this questionnaire if you are interested in using Ozempic with JLUXE Aesthetics
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Do you have issues with losing weight?
*
Yes
No
Do you have insulin resistance?
*
Yes
No
Do you have Type 1 Diabetes?
*
Yes
No
Do you have Type 2 Diabetes?
*
Yes
No
Do you have a past medical history of pancreatitis?
*
Yes
No
Do you or a member of your family have a history of thyroid cancer?
*
Yes
No
Have you or a member of your family been diagnosed with multiple endocrine neoplasia type II?
*
Yes
No
Do you have eye problems? Diabetic Retinopathy?
*
Yes
No
Do you have a history of renal disease or kidney problems?
*
Yes
No
Are you pregnant or breastfeeding? Or plan to get pregnant in the near future?
*
Yes
No
Are you taking any other diabetic medications?
*
Yes
No
Do you have a history of low blood sugar?
*
Yes
No
Do you have any gallbladder issues?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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