GLP-1 Patient Intake Form Template
A comprehensive patient intake form is the foundation of any safe and compliant GLP-1 weight loss program. This template covers the essential clinical, demographic, and screening information providers need before prescribing semaglutide, tirzepatide, or other GLP-1 receptor agonists. Designed for primary care practices, weight loss clinics, and med spas adding cash-pay GLP-1 programs, this form includes BMI documentation, cardiovascular risk screening, medication reconciliation, and contraindication checks required by clinical guidelines. Every section is aligned with current FDA labeling requirements and AACE/ACE obesity management recommendations.
Form Preview
Section 1 of 6
Patient Demographics
Please provide your contact and basic information.
Full Name *
Jane Smith
Date of Birth *
...
Biological Sex *
Female
Phone Number *
(555) 000-0000
Email Address *
Emergency Contact Name & Phone *
...
Section 2 of 6
Weight & BMI
Your current measurements help us determine the right program for you.
Current Weight (lbs) *
185
Height *
5'6"
Goal Weight (lbs)
155
Highest Adult Weight (lbs)
210
Previous Weight Loss Attempts
Diet, exercise, medications tried...
Section 3 of 6
Medical History
Please check any conditions you have or have had.
Current Medical Conditions
Do any of the following apply to you?
Previous Surgeries
List any previous surgeries and approximate dates
Known Allergies *
Medications, foods, environmental allergies
Are you allergic to any of the following?
Section 4 of 6
Current Medications
Please list everything you're currently taking.
Current Medications *
List all current medications, dosages, and frequency
Current Supplements
Vitamins, herbal supplements, OTC medications
Are you currently taking insulin or sulfonylureas?
Section 5 of 6
Lifestyle & Goals
Help your provider personalize your treatment plan.
Smoking / Tobacco Status *
Never
Alcohol Use *
None
Primary Weight Loss Goal *
Improve overall health
Exercise Frequency *
Sedentary (little to no exercise)
Dietary Preferences or Restrictions
Vegetarian, keto, food allergies, etc.
Section 6 of 6
Referral & Payment
A few final details to get started.
How did you hear about this program?
Doctor referral
Primary Care Physician Name
...
Payment Method *
Credit/Debit Card
This is a preview. Actual form will be customized with your practice branding.
Compliance & Regulatory Notes
GLP-1 receptor agonists carry an FDA boxed warning regarding thyroid C-cell tumors observed in rodent studies. All intake forms must screen for personal or family history of medullary thyroid carcinoma (MTC) and MEN 2 syndrome. See FDA labeling: https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/215256s007lbl.pdf
BMI eligibility criteria for GLP-1 weight management follow FDA-approved indications: BMI >= 30 kg/m2, or BMI >= 27 kg/m2 with at least one weight-related comorbidity (hypertension, type 2 diabetes, dyslipidemia).
Medication reconciliation should flag concurrent use of insulin or sulfonylureas, which may require dose adjustment to reduce hypoglycemia risk when initiating GLP-1 therapy.
Practices using compounded semaglutide must comply with applicable state pharmacy board regulations and FDA guidance on 503A/503B compounding. See FDA compounding guidance: https://www.fda.gov/drugs/human-drug-compounding
Patient intake data must be stored and transmitted in compliance with HIPAA Privacy and Security Rules (45 CFR Parts 160 and 164). See HHS HIPAA guidance: https://www.hhs.gov/hipaa/index.html
Want This Form Automated?
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- E-signatures, HIPAA compliance, and audit trail
Related Clinical Forms
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View template →Weight Loss Screening Questionnaire
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View template →Telehealth Weight Loss Consent Form
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View template →Sources & References
Frequently Asked Questions
What should a GLP-1 patient intake form include?
A GLP-1 intake form should capture patient demographics, BMI/weight history, medical history (including contraindication screening for MTC and MEN 2), current medications, allergies, lifestyle factors, and payment information for cash-pay programs. The form must screen for FDA-listed contraindications before prescribing.
Is a separate intake form needed for semaglutide vs. tirzepatide?
The core intake form can be used for both semaglutide and tirzepatide programs, as the contraindication screening and medical history requirements are similar. However, separate consent forms may be appropriate since tirzepatide has a distinct mechanism of action (dual GIP/GLP-1 agonist).
Do I need a different form for compounded vs. brand-name GLP-1 medications?
The intake form is the same regardless of medication source. However, if you are prescribing compounded semaglutide, you should add a consent disclosure explaining the compounded nature of the medication and that it is not FDA-approved in its compounded form. A separate consent form is recommended.
Can I use this intake form for telehealth GLP-1 consultations?
Yes, this form works for both in-person and telehealth consultations. For telehealth, you should also collect a telehealth-specific consent form covering technology requirements, privacy, and state-specific telehealth prescribing regulations.
How often should GLP-1 patient intake forms be updated?
Review and update your intake forms at least annually, or whenever FDA labeling changes, state regulations are updated, or your program adds new medications. Track regulatory changes through FDA MedWatch and your state medical board.