What is your weight loss goal? *

Lose 1–20 lbs for good

Lose over 50 lbs for good

Maintain my weight and get fit

Haven’t decided yet

What is your Height? *

What is your current weight? *

What is your Gender *

Date of birth *

State *

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

Does any of the following apply to you? *

Currently or possibly pregnant

Breastfeeding or bottle feeding with breast milk

End stage kidney disease (on or about to be on dialysis)

End stage liver disease

Current or prior eating disorder (Anorexia/Bulimia)

Current suicidal thoughts and/or suicidal attempts

Cancer (Active diagnosis, active treatment, or in remission or cancer free for less than 5 continuous years; Doesn’t apply to melanoma or skin cancer that was considered cured via simple excision alone

None of the above

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

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

Yes

Please list any medication here

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

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

Yes

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

Yes

If yes, provide details:

Are you willing to: *

Reduce your caloric intake alongside medication, if clinically appropriate.

Increase your physical activity alongside medication, if clinically appropriate.

Neither of the above.

How has your weight changed in the last 12 months? *

Do any of these apply to you? *

Depression

Gallbladder disease

Alcohol/Substance abuse disorder

Seizure

Glaucoma

History of Pancreatitis

Personal or family history of Thyroid Cyst/nodule, thyroid cancer, medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2

None of the above

Do any of the following weight-related medical conditions apply to you? *

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

If yes, please list the details below:

Based on your specific medical history and lifestyle, are you concerned about: *

Loss of muscle mass while taking GLP-1 medications.

Inability or unwillingness to inject yourself once weekly with GLP-1 medications.

Side effects, such as Nausea and Vomiting.

Aging and longevity (Cellular/DNA damage, immune system dysfunction, etc)

Cognitive function and mental clarity

Desire to regulate menses and hormonal status

Poor sleep quality

None of the above

Do you have any severe gastrointestinal condition (e.g. gastroparesis, blockage /Irritable Bowel disease)? *

Yes

If yes, then share the details here

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

Yes

If yes, please state here:

First Name *

Last Name *

What's your email? *

What's your phone number?