GLP-1 Treatment Reassessment

1. Your details

So we can match this to your patient file.

First name

Last name

Email Phone number Date of birth Province or state your medication ships to

2. Your current treatment

Which medication are you currently prescribed? Semaglutide Tirzepatide Another GLP-1 medication I am not currently taking anything Current dose (for example, 0.5 mg weekly) How long have you been on treatment? Less than 1 month 1–3 months 3–6 months 6–12 months Over 12 months Date of your most recent dose How many doses have you missed in the last 4 weeks? None 1 2 3 or more What would you like to do with your dose? Keep it the same Increase it Decrease it Let my provider decide

3. Your progress

Height

Starting weight (lbs)

Current weight (lbs)

Goal weight (lbs)

How is your weight trending? Losing steadily Losing slowly Plateaued — no change recently Gaining

4. Side effects since your last review

Select everything you have experienced.

Nausea Vomiting Diarrhea Constipation Acid reflux or heartburn Injection site reaction Fatigue Headache Dizziness or lightheadedness Hair thinning Severe or persistent abdominal pain Rapid or irregular heartbeat Dehydration or inability to keep fluids down None of the above Overall, how severe have your side effects been? None Mild — manageable Moderate — affecting daily life Severe — I am considering stopping Anything you want to add about your side effects?

5. Health questions, part 1

Do any of these apply to you now?

End stage kidney disease (on or about to be on dialysis) End stage liver disease (cirrhosis) Current suicidal thoughts and/or prior suicidal attempt Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years — does not apply to non-melanoma skin cancer that was considered cured via simple excision) Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease) Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependency None of the above

6. Health questions, part 2

Do any of these apply to you now? Include anything newly diagnosed since your last review.

Untreated hypothyroidism Gallbladder disease Hypertension (high blood pressure) Seizures Glaucoma Sleep apnea Type 2 diabetes (not on insulin) Type 2 diabetes (on insulin) Type 1 diabetes Diabetic retinopathy (diabetic eye disease, damage to the optic nerve from trauma or reduced blood flow, or blindness) History of or current pancreatitis Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2 Gout High cholesterol or triglycerides Depression Head injury Tumor, infection or injury to the brain or spinal cord Low sodium Liver disease, including fatty liver Kidney disease Elevated resting heart rate (tachycardia) Coronary artery disease or heart attack/stroke in last 2 years Allergic to any medication Congestive heart failure QT prolongation or other heart rhythm disorder Hospitalization within the last 1 year Human immunodeficiency virus (HIV) Acid reflux Urinary stress incontinence Polycystic ovarian syndrome (PCOS) Clinically proven low testosterone Osteoarthritis Constipation None of the above

7. Medications and history

Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs? No Yes Have you had any weight loss surgery since your last review? No Yes Have you started any new prescription medications since your last review? No Yes List all prescription medications and supplements you currently take List any medication allergies Are you pregnant, breastfeeding, or trying to become pregnant? No Yes Not applicable

8. Your vitals

What is your current blood pressure range? < 120/80 — Normal 120–129/<80 — Elevated 130–139/80–89 — Hypertension Stage 1 ≥ 140/90 — Hypertension Stage 2 I don’t know What is your average resting heart rate? <60 beats per minute — Low 60–100 beats per minute — Normal 101–110 beats per minute — Slightly Fast >110 beats per minute — Fast I don’t know Have you had bloodwork done in the last 12 months? Yes No

9. Your goals

Select the options you are interested in so we can tailor your next cycle.

Maintaining muscle mass as I lose weight Would prefer not to inject Managing potential side effects such as nausea/vomiting Assist with aging and longevity (cellular/DNA damage, immune system dysfunction, etc) Improving cognitive function and mental clarity Improving energy levels Regulating menses and hormonal status Improving sleep quality I’m not sure — I’d like to discuss formulation options with a clinician via a live virtual consult

10. Anything else

Our medical providers review every reassessment within 24 hours.

Do you have any further information which you would like our medical team to know? Yes No If yes, please tell us more I confirm the information above is accurate and complete to the best of my knowledge, and I agree to be contacted by Supplix Health and its medical partners about my treatment.

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