What is your current height & weight?

Feet

Inches

Weight (in lbs)

What is your gender?

Gender

Male

Female

Date of birth

Where are you located?

Country

State

City

What is the main reason you want to make a change?

We can assist with all of these. For the time being, pick the most important to you.

I want to increase my life expectancy

I want to improve my appearance

I want to minimize my health risks

I want to boost my mental health

Are you currently taking or have recently (within the last 12 months) taken medication(s) for weight loss?

Yes, I currently take or have recently (within the last 12 months) taken a GLP-1 medication for weight loss

Yes, I currently take or have recently (within the last 12 months) taken another medication for weight loss

Do you currently take any medications? If so, please include name, dose, and frequency of all your medications.

Yes

Please include name, dose, and frequency of all your medications.

Have you taken any prescription medications to lose weight before?

Yes

Are you currently taking, plan to take, or have recently (within the last 3 months) taken opiate pain medications and/or opiate-based street drugs?

Yes

Please include date range, name, dose, and frequency.

Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?

Yes

Please provide details about your bariatric surgery or abdominal/pelvic surgeries.

Have you ever attempted to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification?

Yes

Please provide brief details?

Are you willing to?

Neither of these

Reduce your caloric intake alongside medication, if clinically appropriate

Increase your physical activity alongside medication, if clinically appropriate

Have you been diagnosed with prediabetes or type 2 diabetes?

Yes

What is your current or average blood pressure range?

What is your current or average resting heart rate range?

Do you have any medication allergies?

Yes

Are you concerned about any of the following to the level of impacting your ability to take medication regularly?

None of the below

Injecting yourself under the skin with a needle

Nausea or vomiting as a side effect

Loss of muscle mass as a side effect

Do you have any further information which you would like the doctor to know?

Yes

What is your First and Last name?

First Name

Last Name

What is your Email

Email *

What is your Phone number?

Phone *

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