Youthology Semaglutide Prequalification

1
What is your full name as it appears on your government issued ID?
First Name
Last Name
2
What is your email address for a copy of these responses?* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
What is your birthdate?* This field is required.
Date
Year
Month
Day
5
Are you a biological male or female?* This field is required.
Male
Female
6
Have your energy levels dropped to the point where fatigue is a real issue?* This field is required.
YESNO
7
Are you losing muscle mass and muscle definition?* This field is required.
YESNO
8
Are you gaining fat around your abdomen and looking more pear shaped?* This field is required.
YESNO
9
Is your libido down and your desire for sex waning?* This field is required.
YESNO
10
Do you still wake up with an erection? Or is "morning wood" something in the past?* This field is required.
YESNO
11
Have you lost your mojo?* This field is required.
YESNO
12
Is your passion and zest for live becoming a thing of the past?* This field is required.
YESNO
13
Do your joints and soft tissues ache which negatively affects your activity levels?* This field is required.
YESNO
14
Is it difficult to recover from exercise sessions and work around the house?* This field is required.
YESNO
15
Are you depressed, anxious or emotional?* This field is required.
YESNO
16
Does your skin look thin and saggy? Do you have "man boobs"?* This field is required.
YESNO
17
Do you have blood sugar control issues? Type II Diabetes Mellitus? Metabolic Syndrome?* This field is required.
YESNO
18
Do you have fatty liver disease? Liver dysfunction?* This field is required.
YESNO
19
Are you having trouble losing weight? Do you look at a piece of cake and gain weight?* This field is required.
YESNO
20
Do you have any visual problems or disturbances?* This field is required.
YESNO
21
Have you used testosterone in the past? HcG, Human Growth Hormone, or other anabolic agents?* This field is required.
YESNO
22
Do you have a history of pituitary tumor or pituitary gland abnormalities?* This field is required.
YESNO
23
Do you wish to maintain your fertility?* This field is required.
YESNO
24
Do you suffer from brain fog or memory issues?* This field is required.
YESNO
25
Do you have challenges with focus and attention to detail?* This field is required.
YESNO
26
Do you get up at night and go to the bathroom frequently?* This field is required.
YESNO
27
Is sleep a challenge? Do you feel refreshed in the morning when you awaken?* This field is required.
YESNO
28
Is your cholesterol high?* This field is required.
YESNO
29
Have you suffered a prior heart attack or stroke?* This field is required.
YESNO
30
Do you have bone health issues/osteoporosis?* This field is required.
YESNO
31
Please list add medications you are currently taking, if any.
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Large
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Small
Ok
Ok
32
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
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Ok
33
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
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