Semaglutide Weight loss program
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HEALTH PROFILE
The purpose of the health profile is to determine the client's health status in order to determine their weight loss plan. A client may be advised to seek medical advice based on his or her health profile. The profile must be completed prior to beginning a weight loss program with The Sanctuary-Monroe

 


Primary Physician
Please list any physicians you see and their specialty:
Age
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Height
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Current Weight
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SEMAGLUTIDE/ MONJURNO

What is Semaglutide or Monjurno?

Both weight losss compounds are modified molecules our bodies make, called a GLP-1 analog.

It works by increasing insulin production and lowers glucagon secretion as well as targets areas in the brain that regulate appetite and food intake.

A small change in the molecule allows the drug to last weeks in our bodies rather than the natural version our bodies make, which lasts minutes.

● Delays how quickly our stomachs digest food. Leading to a feeling of fullness and satisfaction with smaller meal sizes.

● Slows intestinal motility so you will feel fuller longer after meals.

● Lowers blood sugars, in part by reducing the production of sugar in the liver.

● Stimulates insulin secretion by the pancreas.How Does it Work?

Both Medications acts in the following ways:

● Delays how quickly our stomachs digest food. Leading to a feeling of fullness and satisfaction with smaller meal sizes.

● Slows intestinal motility so you will feel fuller longer after meals.

● Lowers blood sugars, in part by reducing the production of sugar in the liver.

● Stimulates insulin secretion by the pancreas.

 

THOUGHTFUL QUESTIONS TO HELP YOU BRING AWARENESS ABOUT YOUR PATTERNS & HABITS RELATED TO YOUR BODY & MIND. AWARENESS OF THESE PATTERNS WILL LEAD TO CHANGING, LETTING GO, OR ADDING HABITS THAT LEAD YOU TO A LIFETIME OF SUCCESS.  

OUR GOAL IS TO ENCOURAGE YOU THROUGH THIS JOURNEY OF SELF LOVE AND SELF WORTH.  IT'S NOT ABOUT THE FOOD IT IS DIRECTLY RELATED TO YOUR SELF WORTH, HOW YOU NAVIGATE STRESS AND PUTTING YOURSELF AT THE FRONT OF THE LINE.

STACKING HEALTHY HABITS AND LOVING THIS WAY OF LIFE IS WHAT WE WANT FOR YOU. 

YOU WILL START BUILDING YOUR TOOLBOX OF HEALTHY HABITS AND SELF LOVE. SEMAGLUTIDE WILL BE AN IMPORTANT STEP TOWARDS THIS LIFE YOU WANT AND YOUR HEALTHY RELATIONSHIP TO YOUR BODY.  


What is your morning routine?

A great, easy, and doable morning routine will set you up for success for the whole day. 



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  Do you exercise?  
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Any drug use including edibles or smoking Marijuana? 
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Do you smoke cigarettes/vape? 
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What form of exercise do you enjoy?
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How often do you exercise?  
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How does exercise make you feel? 
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If you don't exercise, how do you feel?
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Do you follow a diet and what food works the best for you?

What will set you up for success to commit to having the body you want?


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How is your sleep?
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How much stress are you feeling? 1-10?

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What tools do you use to destress and have peace? 
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Besides food what would make the biggest difference to lose extra weight and feel fabulous?


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What are 3 things you love about yourself? What are 3 things that you would like to improve?


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What patterns are you aware of that keep you stuck in not achieving your health goals?

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What patterns are you aware of that keep you stuck in not achieving your health goals?

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Do you have healthy food available for your meals or snacks? 
Clear selection


Do you have premade healthy food?

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Do you cook?
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How much water do you drink a day?
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How is your gut health? Regular bowel movements?  Have you taken Antibiotics in the past year? When do you get bloated?  Are you gassy or do you feel lethargic after eating? 

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What exactly do you want your body to look and feel like? Don't hold back.  


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What are you holding onto that needs to be released? That doesn't serve you or keep you protected anymore? 

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DIABETES:

please type yes if any of these apply

Do you have diabetes?


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CARDIOVASCULAR FUNCTION:

please check boxes if any of these apply.


KIDNEY FUNCTION

GASTROINTESTINAL FUNCTION

 

NEUROLOGICAL & EMOTIONAL HEALTH

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GENERAL HEALTH 
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Do you have any other health issues?
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Do you have food Allergies?

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How much water do you drink a day or other beverages?__________

How much coffee or Tea you drink a day?____________

How much Alcohol do you drink a day or in a week? ___________________


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MEDICATIONS:

PLEASE LIST ALL MEDICATIONS & SUPPLEMENTS


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INDICATIONS FOR USE OF SEMAGLUTIDE:

1. BMI above healthy range

2.  Type 2 Diabetic

3.  CAD (coronary heart disease)

4. HTN (hypertension)

5. High LDL or Low HDL or Increased triglycerides. 

6. At least 1 weight related disease. 



PRECAUTIONS WITH USE OF SEMAGLUTIDE:

 

1. certain eye problems aka: diabetic retinopathy

2. disease of the pancreas aka:  pancreatitis

3. Gallbladder disease

4. Kidney problems

5. stomach or intestinal disorders aka:  gastroparesis or digestive problems

6. Thyroid Disease


STRICT CONTRAINDICATIONS FOR USE OF SEMAGLUTIDE:

 

1. Personal or family History of Medullary thyroid cancer

2. Multiple endocrine neoplasia

3. Type 1 diabetic

4. Pregnancy

5. Allergy to any of the ingredients (B12) 

 


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I confirm that the information that I have provided to The Sanctuary MD Wellness Center is true, complete, and accurate and that I have not withheld or otherwise omitted, whether in whole or in part, any information concerning my health status.  In this respect, I confirm that I have disclosed all past and present physical and or mental health issues or concerns that I have experienced, including diagnoses, or surgeries that I have had. Medications and supplements that are prescribed or that I take. 

I understand that if I have not disclosed medical information to The Sanctuary MD Wellness Center and I chose to follow the Weight Loss Protocol provided by The Sanctuary MD Wellness Center, such decisions will be completely voluntary. Also, The onsite RN or APRN and Dr. Ken Starr release and discharge The Sanctuary MD Wellness Center and Dr. Ken Starr MD from any & all damages, liability, claims and causes of action of any nature whatsoever that may result from such voluntary and informed decision of this weight loss program provided by The Sanctuary MD Wellness Center 

By signing this contract, I am Agreeing to release all medical malpractice. I Choose to have any issues decided by neutral arbitration and I am giving up my right to jury or court trial.  The weight loss program has been thoroughly explained to me and I have had opportunities to ask any questions or express any concerns and these questions or concerns have been answered to my satisfaction. I understand that neither of the medications above have been approved by the FDA for weightloss.

I am committed to a once a week on the same day of each week for the entire program.  If you miss a day, there are no refunds. Please let me know if you will be out of town the week before, so I can arrange other options. 

Are you 100% committed to health, self-love and honoring who you are?   You are loved and you are worthy!

I have read and understand these risks completely and give my consent for treatment of Semaglutide. 

 


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