Patient Intake Form

Patient Intake & Assessment Form — Leanova Health

Patient Intake & Assessment Form Step 1 of 6 · 0% complete

A1–A3 Demographics

A4–A6 Medical

A7–A9 Meds & Goals

B1–B3 Diet

B4–B6 Lifestyle

Consent & Submit

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Your intake form has been received by the Leanova clinical team. Your doctor will review it before your consultation. You will be contacted to confirm next steps.

Questions? Write to care@leanova.in

Block A — Medical Assessment

Medical History, Sleep Screening & Family History

This section helps your doctor identify comorbidities, safety considerations, and relevant family risk factors.

A5 — STOP-BANG Questionnaire (Sleep Apnoea Screen)

Score ≥ 3: High risk for OSA — further evaluation recommended before initiating GLP-1 therapy.

	Question	Yes	No
S	Do you snore loudly?	Yes	No
T	Do you often feel tired, fatigued, or sleepy during the daytime?	Yes	No
O	Has anyone observed you stop breathing during your sleep?	Yes	No
P	Do you have or are you being treated for high blood pressure?	Yes	No
B	BMI > 35 kg/m²?	Yes	No
A	Age > 50 years?	Yes	No
N	Neck circumference > 40 cm?	Yes	No
G	Gender: Male?	Yes	No

Fatigue severity

Difficulty concentrating

Insomnia severity

Step 2 of 6

Block A — Medical Assessment

Medications, Safety Screen & Programme Goals

This section ensures safe prescribing and helps your doctor understand your treatment goals.

A7 — Current Medications & Supplements

List all current medications, supplements, and OTC drugs. Include dose and frequency.

Medication name	Dose	Frequency	Indication / reason

Known drug allergies or adverse reactions *

Yes — specify below No Unsure

Specify drug name and nature of reaction (if applicable)

A8 — Contraindications & Safety Screen

⚠Any YES response requires physician review before prescribing GLP-1 / GIP therapy. Do not proceed with medication initiation until cleared.

Safety item	Yes	No	Unsure
Known allergy to GLP-1 receptor agonists (semaglutide, tirzepatide, liraglutide)	Yes	No	Unsure
Personal or family history of MTC or MEN2 syndrome	Yes	No	Unsure
History of acute or chronic pancreatitis	Yes	No	Unsure
Active gallstones / symptomatic cholelithiasis	Yes	No	Unsure
Estimated GFR < 15 mL/min/1.73m² (severe renal impairment)	Yes	No	Unsure
Current pregnancy, planning pregnancy within 6 months, or breastfeeding	Yes	No	Unsure
Active eating disorder (anorexia nervosa, bulimia, binge-eating disorder)	Yes	No	Unsure
Active suicidal ideation or recent (within 3 months) psychiatric hospitalisation	Yes	No	Unsure

Step 3 of 6

Declaration & Consent

Review, Consent & Submit

Please read the declaration below and confirm your consent before submitting your intake form.

Step 6 of 6

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