Weight-Loss Clinic Intake | Mediglen Pharmacy Coquitlam

Step 01

About you

We confirm identity by phone before dispensing, so please match your BC Services Card.

Legal first name *

Legal last name *

Date of birth *

BC Personal Health Number (PHN) *10-digit number on your BC Services Card

Sex assigned at birth *Used for medical screening only

Pronouns (optional)

Phone *

Email *

Preferred contact method

Street address *

City *

Province *

Postal code *

Please complete the required fields marked with an asterisk.

Step 02

Body and goals

Used to calculate BMI and confirm eligibility. Please use metric units.

Height (cm) *

Current weight (kg) *

Body mass index

--Enter height and weight

Goal weight (kg)

Highest adult weight (kg)

Waist circumference (cm, optional)

Please enter your height and weight.

Step 03

Weight history

What you have already tried helps the prescriber choose the right therapy.

How long have you been working on your weight?

Approaches you have tried (select all that apply)

Diet or nutrition program Structured exercise Dietitian or coach Over-the-counter products

Have you taken weight-loss medication before?

Which medication(s), and how did you respond?

Have you had bariatric (weight-loss) surgery?

Type and year

Step 04

Medical history

Please be thorough. This is the safety screen the prescriber relies on.

Do you have any of these conditions? (select all that apply)

High blood pressure Heart disease or prior heart attack/stroke Pancreatitis (past or present) Gallbladder disease or gallstones Kidney disease Liver disease Thyroid disease Gastroparesis or severe reflux

Any other medical conditions?

Personal or family history of medullary thyroid carcinoma (MTC) or MEN 2? *Required safety screen for GLP-1 therapy

Thank you. A pharmacist will review this carefully with you; it may affect which medication is appropriate.

Diabetes status

Most recent A1c (%)

A1c date

Current diabetes medications

Current medications (all)

Allergies

Mental health history (optional)Depression, anxiety, or history of an eating disorder

Please answer the required thyroid/MEN 2 screening question.

Step 05

Lifestyle

A quick picture of daily habits.

Tobacco / vaping

Alcohol

Physical activity

Are you pregnant, planning pregnancy, or breastfeeding?GLP-1 medications are not used in pregnancy

Anything stressful affecting your health right now? (optional)

Step 06

Care team and preferences

So we can coordinate with your family doctor and set up your medication.

Do you have a family physician or nurse practitioner?

Provider name

Clinic

Clinic fax (if known)

Medication preference (the prescriber makes the final decision)

Injection support

Pickup or delivery

Questions for the pharmacist or prescriber (optional)

Step 07

Consent and submit

Please read and confirm each item. All four are required.

When you submit, your answers are compiled into a one-page clinical summary and sent securely to the Mediglen pharmacy team. A pharmacist will contact you at the number you provided. Please do not use this form to send emergency messages.

Please confirm all four consent items to submit.

Thank you, your intake is in.

A Mediglen pharmacist has received your summary and will contact you within one business day. If it is urgent, please call 778-285-8811.

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