Aminova Research — Free Medical Questionnaire
3. Do you have a weight loss goal?
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3. Do you have a weight loss goal?
6. What is your current weight?
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7. Do you have a primary care provider?
7. Do you have a primary care provider?
8. How would you describe your regular physical activity?
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8. How would you describe your regular physical activity?
9. Are you pregnant, trying to conceive, or breastfeeding?
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9. Are you pregnant, trying to conceive, or breastfeeding?
10. Do you have a personal or family history of medullary thyroid cancer or MEN2?
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10. Do you have a personal or family history of medullary thyroid cancer or MEN2?
11. Do you have a history of pancreatitis?
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11. Do you have a history of pancreatitis?
12. Do you have Gallbladder disease (stones/cholecystitis)?
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12. Do you have Gallbladder disease (stones/cholecystitis)?
13. Do you have kidney disease or do dialysis?
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13. Do you have kidney disease or do dialysis?
14. Do you have liver disease (hepatitis, cirrhosis, ALT/AST >3x ULN)?
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14. Do you have liver disease (hepatitis, cirrhosis, ALT/AST >3x ULN)?
15. Do you have heart disease or arrhythmia?
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15. Do you have heart disease or arrhythmia?
16. Do you have Type 1 diabetes OR currently using insulin?
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16. Do you have Type 1 diabetes OR currently using insulin?
18. Cancer (active or within the last 5 years)?
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18. Cancer (active or within the last 5 years)?
19. Do you have an autoimmune disease or an active infection?
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19. Do you have an autoimmune disease or an active infection?
20. Do you have copper metabolism disorder (e.g., Wilson’s disease)?
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20. Do you have copper metabolism disorder (e.g., Wilson’s disease)?
21. Do you have a history of melanoma or atypical/dysplastic moles?
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21. Do you have a history of melanoma or atypical/dysplastic moles?
22. Allergies to any of the following?
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22. Allergies to any of the following?
23. If you have any other allergy, please specify.
24. Please describe your current health status, including any chronic conditions or recent health issues.
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25. What are your weight or wellness goals?
26. Do you have a fear of needles, unable to tolerate self-injections, unable to have someone consistently help you with the injection, or unable to see the syringe to safely inject a medication?
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26. Do you have a fear of needles, unable to tolerate self-injections, unable to have someone consistently help you with the injection, or unable to see the syringe to safely inject a medication?
27. People have different sensitivities to medications and commonly experience side effects to standard dosing regimens. Do you commonly experience side effects to medications and often require lower doses to avoid side effects?
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27. People have different sensitivities to medications and commonly experience side effects to standard dosing regimens. Do you commonly experience side effects to medications and often require lower doses to avoid side effects?
28. Have you previously used GLP-1 medications or other weight loss drugs?
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28. Have you previously used GLP-1 medications or other weight loss drugs?
29. If you selected 'Yes', please specify which medication and current dosage.
30. Which medications are you interested in?
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30. Which medications are you interested in?
