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Weight Loss Checkout - Health History
Lets look at your health history to see if Semaglutide is right for you
10
Questions
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HIPAA
Compliance
1
Who do we have the pleasure of helping on their unique weight loss journey?
*
This field is required.
What is your first name?
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2
Great to meet you! What is your last name?
*
This field is required.
Enter your last name below
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3
Who do we have the pleasure of helping on their unique weight loss journey?
What is your full name?
First Name
Last Name
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4
Whats a good email address?
*
This field is required.
example@example.com
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5
Best Number to Reach You?
*
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Please enter a valid phone number.
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6
As we grow older our body begins to change. To best understand your unique situation, we'll need to get your birthday.
*
This field is required.
What is your birthdate?
-
Date
Year
Month
Day
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7
What is your biological sex?
*
This field is required.
Male
Female
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8
Where are you located?
*
This field is required.
Select the state you are located in
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Deleware
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Deleware
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
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9
What is your current weight and height?
*
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10
Have you ever been diagnosed with any of the following medical conditions? Please check all that apply.
*
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Arthritis
Anorexia / Bulimia
Autoimmune Disorders
Bowel Disorders
Cancer
Depression
Diabetes (Type I)
Diabetes (Type II)
Heart Disease
High Blood Pressure
High Cholesterol
Hypoglycemia
Kidney Disease (Not Stones)
Mental Illness
Medullary Thyroid Cancer
Stroke
None of these
Other
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11
If you have ever had a Stroke, Thyroid issues, Kidney Disease (Not Kidney Stones), Cancer, Heart Disease, or have been diagnosed with Anorexia or Bulimia, please describe your condition to the best of your knowledge. (If none, please type NONE)
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