Youthology Custom Weight Loss Treatment Prequalification

1
What is your full name as it appears on your government issued ID?
First Name
Last Name
2
What state do you live in?* This field is required.This is the state where your medication will be shipped to, if prescribed.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
3
Terms and Conditions
4
What is your email address for a copy of these responses?* This field is required.
example@example.com
5
Phone Number* This field is required.
Please enter a valid phone number.
6
What is your birthdate?* This field is required.
Date
Year
Month
Day
7
Are you a biological male or female?* This field is required.
Male
Female
8
Do you have challenges losing weight?* This field is required.
YESNO
9
Do you have problems with blood sugar control?* This field is required.
YESNO
10
Do you have Type I Diabetes Mellitus?* This field is required.
YESNO
11
Do you have Type II Diabetes Mellitus?* This field is required.
YESNO
12
Do you have past medical history for pancreatitis or alcohol abuse?* This field is required.
YESNO
13
Do you or a family member have a history of thyroid cancer?* This field is required.
YESNO
14
Do you or a family member have a history of multiple endocrine neoplasia type II?* This field is required.
YESNO
15
Do you have a history of eye problems? Diabetic retinopathy?* This field is required.
YESNO
16
Do you have a history of renal disease or kidney dysfunction?* This field is required.
YESNO
17
Have you been treated with any of the following weight loss medications?
Rybelsus
Wygovy
Ozempic
Mounjaro
Other
18
When was your last dose administered and what was the dosage?
19
Do you have a history of gallbladder disease?* This field is required.
YESNO
20
Are you capable of and willing to perform injections?* This field is required.
YESNO
21
Do you have a history of hypoglycemia?* This field is required.
YESNO
22
Have you been diagnosed with PCOS (Polycystic Ovarian Syndrome)?* This field is required.
YESNO
23
Are you pregnant?* This field is required.
YESNO
24
Are you experiencing any of the following symptoms? Check all that apply.
Brain Fog
Memory Issues
Word Recall Difficulty
None of the Above
25
Do you have fatty liver or non-alcoholic fatty liver disease?* This field is required.
YESNO
26
Do you have any allergies (food, medicine, or both)?* This field is required.
YESNO
27
Please list all allergies starting with medicine and ending with food allergies:
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Large
Normal
Small
Ok
Ok
28
Please list add medications you are currently taking, if any.
Huge
Large
Normal
Small
Ok
Ok
29
Do you have any additional medical information that you feel would be helpful for your doctor to know when reviewing your information and lab results?
0/100
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Small
Ok
Ok
30
If approved, what is your shipping address to send the medication?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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