Medical Weight Loss Questions: Fill out some info and we will be in touch shortly. We can't wait to hear from you! 1.) Name * First Name Last Name 2.) Date of Birth * MM DD YYYY 3.) Cell Phone # * (###) ### #### 4.) Email 5.) Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country 6.) Shipping Address Address 1 Address 2 City State/Province Zip/Postal Code Country 7.) How long have you tried to lose weight? * a.) Only recently b.) Last few years c.) Decades d.) Entire life 8.) Which of the following symptoms have you experienced? * a.) Low energy or fatigue b.) Poor Mental Health of depression c.) Joint pain or injury d.) Difficulty sleep or snoring e.) Other 9.) Which of the following are you most concerned about? * a.) Improving general health b.) Longevity or disease prevention c.) Discomfort or Pain d.) Confidence/Body Image e.) Something else 10.) How did you hear about us? 11.) Primary Care Physician? 12.) Primary Care Physician Phone Number? (###) ### #### 13.) What methods have you tried in the past to lose weight? Self-management diet (keto, paleo, etc.) * a.) Commercial diet plan (Atkins, weight watchers, etc) b.) Supplements or over the counter treatments c.) Exercise or personal training d.) Prescription medication e.) Something else f.) None 14.) Are you taking Levothyroxine (Common brands: Synthroid, Tirosint, Levoxyl)? * Yes No 15.) Do you have diabetes? * ** If type 1, they do not qualify a.) Type 1 b.) Type 2 c.) No 16.) Do you have diabetic retinopathy? * Yes No 17.) Do you have kidney disease? * Yes No 18.) Do you or your family members have a history of thyroid cancer? Yes No 19.) Any current cancer? * Yes No 20.) Are you pregnant or trying to become pregnant? Yes No 21.) Are you breastfeeding? ** If yes, they do not qualify. Yes No 22.) Do you have depression, suicidal thoughts or mental health issues? Yes No 23.) Do you have any history with alcohol abuse? Yes No 24.) Do you have any history of drug abuse? Yes No 25.) Do you have any Cardiac (Heart) issues? ** If yes, What type? Yes No 26.) Do you have any stomach/intestinal disorders? ** If yes, What type? Yes No 27.) Do you smoke? ** If yes, # of cigarettes per day: How long? Past Smoker? Yes or No Yes No 28.) Please list any medications you are taking. List Medicine Name (separated by comma). 29.) List any existing medical conditions not covered. 30.) List any medications you are allergic to. 31.) List any prior surgeries you've had. 32.) Height 33.) Current Weight 34.) Goal Weight 35.) Gender Male Female 36.) Have you taken GLP-1 medication before? * Yes No 37. Which GLP-1 medication have you taken before? * a.) Mounjaro b.) Wegovy c.) Zepbound d.) Compound Tirezepatide e.) Compound Semaglutide f.) Ozempic g.) None Thank you!