Medical Questionnaire

Basic Info

Age

Height(cm)

Weight(kg)

Waist(cm)

How to measure your waist correctly: Stand upright with your abdomen relaxed and your feet 25–30 cm apart. Find the top of the iliac bone and the lower edge of the ribs. Your waist is midway between these two points, regardless of whether the navel is above or below. Measure the circumference with a tailor’s tape after a relaxed exhalation. Make sure the tape is horizontal and snug against the skin all the way around. A waist circumference greater than 88 cm in women or 102 cm in men is considered a risk factor that may indicate eligibility for treatment with Wegovy.

Medical History

Do you have or have you had in the past one or more of the following diseases?

Non-Exclusion

Non-active oncological disease (which? previous breast cancer or testicular cancer or skin tumor) Thyroid/metabolic disease Dyslipidemia (hypercholesterolemia, hypertriglyceridemia) Sleep apnea (provide documentation) Arterial hypertension Osteoarticular diseases treated with anti-inflammatory drugs

Do you have other conditions?

Yes No

Do you currently have any other acute/subacute conditions?

Yes No

Do you take medications and/or supplements?

Yes No

Do you have any allergies?

Yes No

Have you had any allergic reaction in the past to medications and/or supplements? – EXCLUSION

Yes No

Lifestyle

Which of the following describe you?

I consume more than 10 alcoholic units/week Smoker Frequent consumption of fast food Sedentary job Physical activity less than 2–3 times per week Frequent consumption of snacks (chips, peanuts, etc.) “Sweet tooth” (candies, biscuits, cakes, sugary drinks) None of the above

Pregnancy (to be completed by women only)

I am pregnant or breastfeeding I am trying to become pregnant I am not trying to become pregnant

In the last 12 months, have you tried to lose weight with a low-calorie diet and physical activity for at least 3–6 months?

Yes No

Have you ever tried other weight loss programs or medications?

Yes No

How would you describe your current diet? (Select all that apply)

How many times per week do you exercise?

Never 1–2 times 3–4 times 5+ times

What type of physical activity do you do?

On average, how many hours of sleep do you get per night?

Less than 5 hours 5–6 hours 7–8 hours More than 8 hours

Do you have plans, in the next 2 months, to travel for more than 4 weeks?

Yes No

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Questionario per accedere al trattamento medico per la perdita di peso di FORMA IDEALE

Basic Info

Medical History

Do you have or have you had in the past one or more of the following diseases?

Lifestyle

Questionario per accedere al trattamento medico per la perdita di peso di FORMA IDEALE 