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Weght Loss Form

What goals do you have for your weight?

Confirm your date of birth

Let us know your age

Weight loss medication shipped directly to you.

Prescribed online and delivered to your door. Bye-bye doctor visits and waiting rooms.

 

 

Let's talk about your health

Next we'll cover your health and medical history as well as treatment options

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What was your sex assigned at birth?

Your sex assigned at birth is important for your healthcare provider to make medical decisions.

Which of the following best describes your ethnicity?

BMI categories are different across ethnicities. Knowing about your ethnicity helps our medical team review your profile.

How tall are you?

We need this to determine your body mass index (BMI) for eligibility and diagnosis.

What is your weight?

We need this to determine your body mass index (BMI) for eligibility and diagnosis.

Do you have any of the following conditions?

Select all that apply.

Do you have any of the following other conditions?

Select all that apply.

Have you been diagnosed with, or do you suffer from any of the following?

Select all that apply.

Do any of these apply to you?

Select all that apply.

Have you had blood work done to test for diabetes, cholesterol and thyroid function in the last 2 years?

Was your blood work normal?

What was abnormal?

Have you ever been diagnosed with an eating disorder?

Have you ever had weight loss surgery?

Select all that apply.

How have you tried to lose weight in the past?

Select all that apply.

How long have you had concerns about your body weight?

How effective were these methods in helping you lose weight?

How would you describe your diet in the past week?

How many days per week do you exercise 30 minutes or more?

Do you believe that your body weight is negatively affecting your health? To what extent?

What do you hope to accomplish by managing your body weight?

Select all that apply.

Tell us more about your goals

Tell us about your lifestyle.

Select all that apply.

Do you have any allergies?

Do you take any other medication, vitamins, herbals, or supplements?

Please enter all medications you currently take, including any and all medications containing Nitroglycerine as well as vitamins, herbals, and supplements.

Have you had any surgeries or hospitalizations?

Please enter any and all past surgeries.

Do you have any medical conditions?

Please enter any and all medical conditions.

Do you have any questions you would like to ask the healthcare practitioner?

Enter your contact info

email / mobile number able to receive sms

Do you confirm that the information you have given is true and accurate, that any prescribed medication is solely for yourself, and that if prescribed, you will review the information provided about the medication?

Warning

We’re sorry, we are unable to offer you treatment at this time.

Please make sure all the information you provided on this patient intake form is true and accurate before continuing.

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