GLP1 New Client Health Questionnaire

1
Name
First Name
Last Name
2
Date
Date
Month
Day
Year
3
Email
example@example.com
4
Phone Number
Please enter a valid phone number.
5
Address
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
6
Preferred Contacts
Phone Call
Email
Phone Message
Other
7
Birth Date
Month
Day
Year
8
Age
Ex:23
9
Gender
Please Select
Please Select
Male
Female
N/A
10
Have You EVER Taken any of the Following:
Semaglutide (Compounded)
Wegovy
Ozempic
Rybelsus
Tirzepatide (Compounded)
Mounjaro
Zepbound
Retatrutide
11
Are You CURRENTLY Taking any of the following:
Semaglutide (Compounded)
Wegovy
Ozempic
Rybelsus
Tirzepatide (Compounded)
Mounjaro
Zepbound
Retatrutide
12
Which Group of GLP1 Monthly Injections Are You Most Interested In?
Semaglutide (Compounded), Wegovy, Ozempic, Rybelsus
Tirzepatide (Compounded), Mounjaro, Zepbound
Retatrutide
Not Sure
13
Do you have any of the following?
High blood pressure
Diabetes - Type 1
Diabetes - Type 2
Gout
14
Are you taking any medications for
Diabetes
Thyroid
High blood pressure
Lithium
High cholesterol
Coumadin (Warfarin)
15
Are you pregnant?
Yes
No
N/A
16
Are you nursing?
Yes
No
17
Do you have any food allergies?
Yes
No
18
Please describe
19
Height
Height in total inches
20
Weight
Weight in lbs
21
Image Field
22
What is your current BMI number?
23
What is the BMI value for the weight you want to maintain at?
24
In general, at what time do you go to bed?
25
In general, when do you wake up?
26
On average, how many hours of sleep do you get?
27
Do you wake up feeling rested?
Yes
No
Other
28
How is the quality of your sleep?
29
In a day, how much water do you drink usually?
30
In a day, how much coffee do you drink usually?
31
In a week, how much alcohol do you consume usually?
32
How many times per week do you exercise?
33
What kind of exercise do you participate in?
34
Are there things you would like to do that you are currently unable to?
35
How would you rate your daily energy level?
1
2
3
4
5
6
7
8
9
10
Worst
Best
36
What do you do for work?
37
Do you enjoy what you do?
38
Are there any excessive ongoing or new sources of stress in your life?
If you do not get a response in 30 minutes feel free to text 314-717-0575
39
Rate your overall stress level
1
2
3
4
5
Lowest
Highest
40
When do you eat your first meal?
41
When do you eat your last meal?
42
How many meals per day do you eat?
43
Do you snack? If yes, what do you snack on?
44
How often do you eat out in a week?
Always
Usually
Sometimes
Rarely
Never
Other
45
Where do you typically eat out?
46
Goal Weight
47
Have you tried to lose weight before?
Yes
No
48
What have you found to be the most difficult part of losing weight in the past?
49
Do you smoke?
1 Pack/day
2 Packs/day
+3 Packs/day
No
50
Do you do any exercise?
1 - 3 a week
3 - 5 a week
Everyday
Never
51
How did you hear about us?
I am an existing client at Shape of You
I was referred by a client of Shape of You
I found you through Google / Search Engine seach
I found you on Social Media
52
Thank You! We will contact you shortly.
53
Type a question
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