Patient Intake Form: GLP-1 & Peptides

First Name *

Last Name *

Date of Birth *

mm/dd/yyyy

Height *

feet, inches

Weight *

lbs

Phone *

Email *

Preferred Contact Method

Text message

Phone call

Occupation *

Top Priorities *

Check up to 3

Weight, Cravings & Metabolism

Do you struggle with food noise, snacking, overeating? *

Have you used GLP-1 medications before? If yes, results/side effects: *

Energy, Focus & Mood

Do you have chronic fatigue, low stamina, or energy crashes? *

Do you experience brain fog, poor focus, forgetfulness? *

Stress, overwhelm, or burnout? *

Recovery, Pain & Inflammation

Slow recovery from workouts/soreness/injuries? *

Chronic joint or tendon pain limiting activity? *

Lingering discomfort from old injury or surgery? *

Sleep, Immune & Detox

Poor sleep, waking often, unrefreshing sleep? *

Get sick easily or slow recovery from illness? *

Regular alcohol, smoking, travel, or toxin exposure? *

Healthy Aging & Appearance

Concerned about aging-related changes? *

Dull skin, fine lines, thinning hair, slower healing? *

Medical History

Have you been told not to take GLP-1 medications? *

History of pancreatitis, thyroid cancer/MEN2, severe GI disease, active cancer, diabetes? *

Pregnant, breastfeeding, or planning pregnancy? *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages and/or phone calls from ChiroMom. *

I agree

I understand that the final treatment recommendations require review by a licensed medical provider. *

I agree