Patient Experience Questionnaire for Weight Loss Medication

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Patient Experience Questionnaire for Weight Loss Medication:

    Select Your Medication

    ID # or First Name (optional):

    Instructions: Please complete form, and answer questions below to provide feedback on your experience of treatment with a weight loss medication. Your responses will help us understand benefits and side-effects you had experienced. The results of the collected data will guide healthcare providers and patients for improvements. An example of completed questionnaire is shown for your help. (Please Click here to see the example).

    Sex *

    Race *

    Information

    Current

    Beginning of Treatment

    Completion of Treatment

    Date (mm/dd/yyyy)

    Age (years and months)

    Weight (kg or lbs)

    Height (inches)

    Body Mass Index* (BMI: ---- kg/m2)

    Waist Circumference (inches)

    Blood Pressure (systolic / diastolic)

    Heart Rate (beats per minute)

    Glycemic Status (Hemoglobin A1C)

    Cardiovascular Illness (heart attack or stroke)

    Yes

    Yes

    Yes

    Fatigue

    Yes

    Yes

    Yes

    Headache (Yes or No)

    Yes

    Yes

    Yes

    Body Aches (Yes or No)

    Yes

    Yes

    Yes

    Abdominal Pain (Yes or No)

    Yes

    Yes

    Yes

    Back Pain (Yes or No)

    Yes

    Yes

    Yes

    Arthritis

    Yes

    Yes

    Yes

    Gastrointestinal Illness (Yes or No)

    Yes

    Yes

    Yes

    Diarrhea (Yes or No)

    Yes

    Yes

    Yes

    Dyspepsia or stomach upset (Yes or No)

    Yes

    Yes

    Yes

    Constipation (Yes or No)

    Yes

    Yes

    Yes

    Asthma (Yes or No)

    Yes

    Yes

    Yes

    How long have you been on this medication?
    Less than 1 month1–3 months4–6 monthsMore than 6 months

    What dosage have you received for your treatment?
    LowMediumHighUnsure

    What benefits have you noticed during treatment with this medication? (Check all that apply)
    Weight lossImproved energy levelsImproved blood sugar controlBetter sleepImproved moodOther (Please specify):

    Did you experience any of the following side effects during treatment? (Check all that apply)
    NauseaVomitingDiarrheaConstipationLoss of appetitePancreatitisLiver diseaseGastroenteritisGallstones (Cholelithiasis)NasopharyngitisLung infections (or Aspiration Pneumonia)Skin reactions at the injection siteOther (Please specify):

    How severe have these side effects been?
    Not noticeableMildModerateSevere

    What was your glycemic status before treatment with weight loss medication?
    Normoglycemic (normal blood glucose)Pre-diabeticDiabeticSeverely diabetic

    Did you experience reversal of weight loss when treatment with this medication was completed?
    After six monthsAfter one yearAfter two yearsLoss of weight was never reversed

    Did you receive the treatment with weight loss medication a second time?
    NoYes

    Overall Experience
    Do you feel the benefits outweigh the side effects?
    YesNoUnsure

    Rate your overall satisfaction with the medication’s benefits:
    Very satisfiedSatisfiedNeutralDissatisfiedVery dissatisfied

    Would you recommend this medication to others seeking weight loss treatment?
    YesNoUnsure

    Additional Feedback
    What improvements, if any, would you suggest for this medication or your treatment plan?

    Please share any additional comments about your experience:

    Thank you for completing this questionnaire!

    Your feedback is valuable in improving care and understanding patient experiences.

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