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Start Your Medical Weight-Loss Evaluation

Full Name

*

Email Address

*

Mobile Number

*

Date of Birth

*

State of Residence

*

Height (ex: 5'4")

*

Weight (Ibs)

*

Is your BMI 30 or above OR BMI 27–29.9 with weight-related conditions?

*

Is your BMI 30 or above OR BMI 27–29.9 with weight-related conditions?

A

Yes

B

No

C

Not sure

Do you have any of the following?

*

Do you have any of the following?

A

Type 1 Diabetes

B

Kidney Disease

C

History of Pancreatitis

D

Gallbladder Disease

E

Gastrointestinal Motility Issues (Gastroparesis)

F

Pregnant or Breastfeeding

G

Diabetic Retinopathy (Vision Impairment)

H

BMI < 27 with NO metabolic conditions

I

Seizures

J

None of the above

Any personal or family history of Medullary thyroid cancer or MEN2?

*

Any personal or family history of Medullary thyroid cancer or MEN2?

A

Yes

B

No

Any allergies to GLP-1 medications?

*

Any allergies to GLP-1 medications?

A

Yes

B

No

Have you used any weight-loss medications before (Ozempic, Wegovy, Mounjaro, Zepbound, Sexanda, Phentermine, etc)?

*

Have you used any weight-loss medications before (Ozempic, Wegovy, Mounjaro, Zepbound, Sexanda, Phentermine, etc)?

A

Yes

B

No

Which medication (s) and how did you respond?

*

What is your primary weight-loss goal?

Untitled multiple choice field

A

Lose 10–20 lbs

*

B

Lose 20–40 lbs

C

Lose 40–60 lbs

D

60+ lbs

E

Not sure yet

How soon are you wanting to start?

Untitled multiple choice field

A

ASAP

*

B

Within 1–2 weeks

C

Just researching options