Medical Weight Loss Questionnaire

First Name *

Last Name *

Phone *

Email *

Date of birth

State

Postal code

City

Address

Are You Currently Taking Medications? *

Yes

If Yes, Please List Them Here

Do You Have Any Known Allergies? *

Yes

If Yes, Please List Them Here

Do you have a history of any of the following conditions (If more than 1, please list in 'other' field)

Type 1 Diabetes

High Blood Pressure

Heart Disease

Kidney Disease

Liver Disease

Autoimmune Disorders

Cancer

Medullary Thyroid Carcinoma or family history of it

Gastroparesis

Severe Hypoglycemia

None

Other

If Other, Please List Them Here

Do you have a family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2? *

Yes

Have you ever had an adverse reaction to any weight loss medications? *

Yes

If you've had adverse reactions to weight loss medications, please elaborate:

Are you currently pregnant, planning to become pregnant, or breastfeeding? *

Yes

Do you have a history of fainting or dizziness? *

Yes

Do you have any bleeding or clotting disorders? *

Yes

What are your primary goals? *

Lose Weight

Improve Blood Glucose Control

Enhance Overall Health

Increase Energy Levels

All of the above

If your goals were not listed above, please list them here:

How often do you exercise? *

Daily

Several Times A Week

Occasionally

Rarely/Never

Do you follow a nutrition plan? *

Yes

If you're on a diet, please describe it here:

Do you consume alcohol? *

Yes

Do you use tobacco products? *

Yes

If yes to alcohol or tobacco, please list how often below:

Do you use recreational drugs? *

Yes

Anything else we should know?

Which Medical Weight Loss Product Are You Interested In? *

Please Choose a Medical Weight Loss Product

Semaglutide
Tirzepatide
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Are You Interested In Our Package Rates? (Save Up To $350!) *

For Huge Savings, Please Select a Three Month Medical Weight Loss Package

Semaglutide Starter: $699
Tirzepatide Starter: $849
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