Weight Loss Follow-Up & Check-In Form

Please complete before your next refill. Your responses update your chart and help me adjust your protocol — no separate visit needed unless something needs attention.

Section 1 — Patient Info

Date of Birth (mm/dd/yyyy)*

Section 2 — Current Medication & Dose

Semaglutide — Weekly Injection
Tirzepatide — Weekly Injection
Sublingual Semaglutide — Daily
Phentermine — Daily
Bupropion
Naltrexone — Daily

Section 3 — Weight Check

Current weight (lbs) (Number field)*
Goal weight (lbs) (Number field — accepts +/-)
Change since last check-in (lbs) (Number field)

Section 4 — How You're Feeling

Label: 1 = poor, 5 = excellent

Energy (Rating 1- 5)
Sleep Quality (Rating 1- 5)
Mood (Rating 1- 5)
Appetite Control (Rating 1- 5)
Cravings / Food Noise (Rating 1- 5)
Overall Well-Being (Rating 1- 5)

Section 5 — Side Effects

Check any you're experiencing

Section 6 — Adherence

Adherence status
Missed doses since last refill

Section 7 — Lifestyle Check

Check what applies

Section 8 — What I Want Next

Patient's preference for next phase*

Section 9 — Anything New or Any Questions?



Thank you! Your responses are now part of your chart and I will review them before your next refill. If anything came up that needs attention sooner, I will reach out directly. — Optimal You Team