Renew MedSpa Weight Loss Medication Check-in Question Title * 1. Your First and Last Name: Question Title * 2. What is your date of birth? DOB Date Question Title * 3. Today’s date: Date / Time Date Question Title * 4. Which medication are you currently taking? If you're not sure, check your medication label. Zepbound/Tirzepatide Injection (weekly injection) Semaglutide Injection (weekly injection) Question Title * 5. Date of your last dose taken: Date / Time Date Question Title * 6. What was the dose of your last injection? This is the mg and number of units injected (If you're not sure, check your medication label) Question Title * 7. For your next refill, are you wanting to lose more weight or be on maintenance dosing? I want to lose more weight I want to be on maintenance dosing Comments: Question Title * 8. If you are on maintenance, do you want to stay on the dose you are on currently? Skip this question if it doesn't apply to you. Yes, stick with dose I'm on No, would like to make adjustments Question Title * 9. What is your height? Question Title * 10. Your weight when you started the program? Question Title * 11. Your weight today: Question Title * 12. How much weight have you lost since starting the program? Question Title * 13. Have you experienced any of the following negative side effects? Please check all that apply. We adjust dosing to relieve negative symptoms. Nausea Vomiting Stomach pain Heartburn Joint pain or inflammation Fast heartbeat Vision changes Diarrhea or constipation Hunger ramping up before next dose Other (please specify) Question Title * 14. Have you noticed any positive effects since being on weight loss medication (e.g., weight loss, sleep better, increased energy, clothes fitting better, elevated mood, etc.)? Yes No If you answered yes, please list. Question Title * 15. Are you journaling your food and water intake? Yes No If you answered yes, what have you noticed (for example patterns, positive changes, areas for improvement, etc.)? Question Title * 16. Have you had any changes to medications or medical conditions since your last refill? If yes, please provide info. Yes No If you answered Yes, please provide detail here. If you don't provide this info, this will delay processing. Question Title * 17. Is there anything that you would like us to be aware of regarding how you are doing? Question Title * 18. Please rate your commitment to weight loss and maintaining your weight loss (1 is not at all committed and 10 is extremely committed). Question Title * 19. I certify that the above information is accurate and correct to the best of my knowledge. By completing this form, I agree to have my refill processed by Renew MedSpa and my card on file to be charged the prescription fee. I agree Done