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Aminova Rx — Free Medical Questionnaire
1. Full Name
*
2. Date of Birth
*
3. Do you have a weight loss goal?
*
3. Do you have a weight loss goal?
A
Yes, I want to lose 5-20 lbs.
B
Yes, I want to lose 21-50 lbs.
C
Yes, I want to lose 51+ lbs.
D
No, I am perfectly happy with my current weight.
4. Email
*
5. Phone Number
*
6. What is your current weight?
*
7. Do you have a primary care provider?
7. Do you have a primary care provider?
A
Yes
B
No
8. How would you describe your regular physical activity?
*
8. How would you describe your regular physical activity?
A
Very active
B
Moderately active
C
Lightly Active
D
Sedentary
9. Are you pregnant, trying to conceive, or breastfeeding?
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9. Are you pregnant, trying to conceive, or breastfeeding?
A
Yes
B
No
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?
A
Yes
B
No
11. Do you have a history of pancreatitis?
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11. Do you have a history of pancreatitis?
A
Yes
B
No
12. Do you have Gallbladder disease (stones/cholecystitis)?
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12. Do you have Gallbladder disease (stones/cholecystitis)?
A
Yes
B
No
13. Do you have kidney disease or do dialysis?
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13. Do you have kidney disease or do dialysis?
A
Yes
B
No
14. Do you have liver disease (hepatitis, cirrhosis, ALT/AST >3x ULN)?
*
14. Do you have liver disease (hepatitis, cirrhosis, ALT/AST >3x ULN)?
A
Yes
B
No
15. Do you have heart disease or arrhythmia?
*
15. Do you have heart disease or arrhythmia?
A
Yes
B
No
16. Do you have Type 1 diabetes OR currently using insulin?
*
16. Do you have Type 1 diabetes OR currently using insulin?
A
Yes
B
No
17. Do you have asthma?
*
17. Do you have asthma?
A
Yes
B
No
18. Cancer (active or within the last 5 years)?
*
18. Cancer (active or within the last 5 years)?
A
Yes
B
No
19. Do you have an autoimmune disease or an active infection?
*
19. Do you have an autoimmune disease or an active infection?
A
Yes
B
No
20. Do you have copper metabolism disorder (e.g., Wilson’s disease)?
*
20. Do you have copper metabolism disorder (e.g., Wilson’s disease)?
A
Yes
B
No
21. Do you have a history of melanoma or atypical/dysplastic moles?
*
21. Do you have a history of melanoma or atypical/dysplastic moles?
A
Yes
B
No
22. Allergies to any of the following?
*
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.
*
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?
*
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?
A
Yes. I would need someone else to inject me and/or would need an oral formulation for a safer experience.
B
No. I’m capable of injecting myself and/or have good support with someone who can consistently help me
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?
*
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?
A
Yes
B
No
28. Have you previously used GLP-1 medications or other weight loss drugs?
*
28. Have you previously used GLP-1 medications or other weight loss drugs?
A
Yes
B
No
29. If you selected 'Yes', please specify which medication and current dosage.
30. Which medications are you interested in?
*
30. Which medications are you interested in?
Semaglutide: Average body weight loss is 10–16% with proper use (Ozempic, Wegovy)
Tirzepatide: Average body weight loss is 15–22% with proper use (Zepbound, Mounjaro)
Retatrutide: Average body weight loss is 20–24% in trials (Retatrutide is currently undergoing phase 3 clinical trials, which are expected to conclude in early 2026.)
NAD+: Anti-aging, boosts cellular energy and DNA repair
Lipo-C (MIC) + B12: Fat metabolism, liver function, energy, nerve support
Glutathione: Master antioxidant; lowers oxidative stress, liver detox, skin brightening
GHK-Cu (Copper Peptide): Boosts collagen/wound healing, reduces inflammation, improves hair/scalp vitality
Vitamin B12: Energy, cognitive support, RBC formation, nerve health
BPC-157 + TB-500: Soft-tissue repair (tendon/ligament), gut health
Tesamorelin: Increases GH/IGF-1, for visceral fat loss, improves body composition markers
SNAP-8 (topical cosmetic): softens fine lines and wrinkles, easy add-on to skincare
KPV: Anti-inflammatory (gut/skin), calms irritation, supports skin barrier, may aid recovery from flare-ups.
Semax: Focus/mental clarity support, neuroprotective, for mood/stress resilience
Epitalon: Longevity peptide, circadian/sleep rhythm support, antioxidant/“healthy aging”
Thymosin Alpha-1 (Tα1): Immune modulation (T-cell support), adjunct in chronic infections in some regions, may enhance vaccine response
PT-141: On-demand boost in sexual desire/arousal (central mechanism; non-hormonal), FDA-approved for HSDD in premenopausal women, supports arousal/erectile function in men
Melanotan: Boosts melanin → faster tanning and some photoprotection, reduces sun sensitivity
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