Fusion Smart Health Fetherlite | GLP-1 Treatment | Intake Form

Tell us about your treatment so far

Your answers help a licensed provider review your history and confirm the right next step. This takes about five minutes.

1 · Your profile
Complete your profile

This information helps us identify a licensed provider in your state to complete your medical assessment. If prescribed, we'll ship your medication to this address.

Your number is only used for order updates and key treatment information.

2 · Treatment history
Are you currently or have you ever taken a GLP-1 medication?

GLP-1s can include compounded semaglutide, compounded tirzepatide, Ozempic, Wegovy, Mounjaro and Zepbound.

Which GLP-1 medication are you currently taking?

Select all that apply.

What dose of injectable tirzepatide (Mounjaro, Zepbound, or compounded) are you taking?

Tell us your current dose in milligrams (mg) per week.

How successful has your tirzepatide (Mounjaro, Zepbound, or compounded) experience been?
Have you experienced any of the following side effects from tirzepatide?

Select all that apply.

Have you experienced muscle loss while taking tirzepatide?
If you're prescribed a GLP-1 medication through us, do you agree to stop taking your current tirzepatide medication?
When was the last date you took your GLP-1 medication?
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Do you have enough medication to maintain your current GLP-1 dose for the next 2 weeks?
Are you happy with your current GLP-1 dose?
3 · Medical background
Do you currently take any medications or supplements?
Do you have any allergies?

Include allergies to food, dyes, prescriptions or over-the-counter medicines (e.g. antibiotics, allergy medications), herbs, vitamins, supplements or anything else.

Do you have any medical conditions or chronic diseases?

This helps your provider get a complete understanding of your medical history. Include any conditions impacting your blood pressure, heart, kidneys (including kidney stones) or liver, and any diseases such as diabetes, high cholesterol, stroke, cancer, or gout.

Have you been diagnosed with any of the following conditions?

Select all that apply.

Have you or a family member ever been diagnosed with any of the following conditions?

We ask because some conditions can determine which treatment types are right for you. Select all that apply.

Have you or a family member ever been diagnosed with type 2 diabetes?

We ask because some conditions can determine which treatment types are right for you.

Do you have a personal history of type 2 diabetes (not including gestational diabetes)?
Has a close family member under the age of 40 passed away unexpectedly?

Close family members can be a parent, sibling or child. We ask this so your provider can determine the appropriate treatment for you.

Have you had any surgeries or medical procedures?

This helps your provider get a complete understanding of your medical history so they can recommend the best treatment for you.

Do you currently have any desire to harm yourself or others?

We ask this question so your provider can have a complete picture of your current health and determine which treatment might be right for you.

If you're in crisis or thinking about harming yourself, contact your local emergency number or a crisis line right away — in the US, call or text 988.

How often do you consume 5 or more alcoholic drinks in one occasion?

Alcohol can affect how some medications work, and your provider needs this to give you the best guidance.

Have you taken any of the following recreational drugs in the past 6 months?

This gives your provider a complete picture of your current health and helps determine which treatment might be right for you. Select all that apply.

Are you currently using any nicotine replacement products to help you stop smoking?

We ask this to make sure there are no interactions with potential treatments.

4 · Vitals
What is your average resting heart rate?

You can find your average resting heart rate if you own a wearable like an Apple Watch or Oura Ring.

When was the last time you or a healthcare provider checked your blood pressure?
Have you had 2 or more blood pressure readings in the last 12 months where your systolic pressure (top number) was 130 or higher, or your diastolic pressure (bottom number) was 80 or higher?
5 · Anything else
Is there anything else your provider should know, or any questions you want to ask?
Something went wrong sending your answers. Please check the highlighted fields and try again.

By submitting this form, I acknowledge and agree that: (1) a licensed healthcare provider will rely on the information I have provided to make clinical decisions about my care, and that false, incomplete, or misleading answers can result in serious harm to my health, including dangerous medication interactions, incorrect dosing, and treatment complications; (2) knowingly providing false or misleading health information may result in denial of treatment, immediate termination of services without refund, and, where applicable, referral under relevant law; (3) I have a continuing obligation to promptly inform my provider if any of the information I have provided changes, including new medications, diagnoses, symptoms, or pregnancy status; and (4) this intake form is a medical questionnaire, not a guarantee of treatment — eligibility is determined solely by a licensed provider. This form does not replace emergency care — if you're experiencing a medical emergency, call your local emergency number.

You're all set

Your intake has been received. A licensed provider will review your answers and follow up with next steps.