Weight-Loss Assessment

First Name

Middle Name

Last Name

Date of Birth

Gender

Phone No

Email Address

Partner Code (Optional)

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

1 Height

Weight (lbs)

BMI

2 Do you have any of the following weight-related conditions?

Type 2 diabetes

High blood pressure

High cholesterol

Sleep apnea

Osteoarthritis or joint pain

PCOS

Fatty liver disease

None of these

3 Are you currently pregnant, trying to become pregnant, or breastfeeding?

Yes

4 Do you have a personal or family history of medullary thyroid carcinoma (MTC) or MEN2?

Yes

5 Have you ever had pancreatitis, severe GI disease, or gastroparesis?

Yes

6 Do you have kidney disease with eGFR < 30 or on dialysis?

Yes

7 Had bariatric (weight-loss) surgery in the past 12 months?

Yes

8 Are you currently taking any of the following?

Insulin

Sulfonylurea

Warfarin

None of these

9 Are you currently taking semaglutide or tirzepatide?

Yes

10 Any allergies to semaglutide, tirzepatide, or similar medications?

Yes

Consents (must check all to proceed)

I consent to e-visits for weight-loss treatment.

I understand the potential risks of GLP-1 medications.

I understand medication will be prescribed after provider review.

I agree to the program’s policies.