Weekly Weight loss Check-in Medical weight loss program weekly patient check-ins. First Name Last Name Did you take your Wegovy dose this week as instructed? Yes No Have you experienced any of the following side effects? (Select all that apply) Nausea Bloating/Gas Constipation/Diarrhea Headache Fatigue No side effects Any other side effects? Current Weight (kg/lbs) How do you feel overall this week? (Scale: 1 = Poor, 5 = Excellent) 1 2 3 4 5 Any Other Concerns or Questions? Submit Your personal data is securely stored and processed in compliance with the General Data Protection Regulation (GDPR). Read our Privacy Policy
