Medical form

1
Let's get you started on your exciting weight loss journey! What is your name?* This field is required.
First Name
Last Name
2
Gender* This field is required.
Male
Female
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Age* This field is required.
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What is your Height in inches? (Conversion table below)* This field is required.4 feet 11 in 59 in 5 feet 60 in 5 feet 1 in 61 in 5 feet 2 in 62 in 5 feet 3 in 63 in 5 feet 4 in 64 in 5 feet 5 in 65 in 5 feet 6 in 66 in 5 feet 7 in 67 in 5 feet 8 in 68 in 5 feet 9 in 69 in 5 feet 10 in 70 in 5 feet 11 in 71 in 6 feet 72 in 6 feet 1 in 73 in 6 feet 2 in 74 in 6 feet 3 in 75 in 6 feet 4 in 76 in 6 feet 5 in 77 in
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Weight (lb)* This field is required.
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BMI
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BMI: Low

Underweight Range

Sorry, your BMI is in the low range. You don't qualify for treatment! BMI must be 27 or greater!
8
BMI: Normal

Normal and Healthy Weight Range

Sorry, your BMI is in the normal range. You don't qualify for treatment! BMI must be 27 or greater!
9
BMI: High

Overweight Range

Sorry your BMI is considered high but you don't qualify for treatment! BMI must be 27 or greater!
10
BMI: High

Overweight Range

You qualify for treatment!
11
BMI: Very High

Obese Range

You qualify for treatment!
12
BMI Result
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Date of birth* This field is required.
Date
Month
Day
Year
14
Email* This field is required.
example@example.com
15
Shipping Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Florida
State
Zip Code
Please Select
Please Select
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The Bahamas
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Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
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Israel
Italy
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Japan
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Kenya
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North Korea
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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
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Samoa
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Senegal
Serbia
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Slovenia
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eSwatini
Sweden
Switzerland
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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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Phone Number* This field is required.
Area Code
Phone Number
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Do you have challenges losing weight?* This field is required.
YESNO
18
List any current or past medical problems. If you have no past medical history click no past medical history or fill in other if not listed* This field is required.
Type 1 Diabetes
Alcohol abuse
Cancer or history of multiple endocrine neoplasia type II
Kidney or Renal disease
History of Pancreatitis
Diabetic retinopathy
Hypoglycemia
Gallbladder disease
Liver disease
Hypertension
High cholesterol
No past medical history
Other
19
Do you have any medication allergies?* This field is required.
YESNO
20
List any allergies and reactions
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Have you had any surgeries?* This field is required.
YESNO
22
List any surgeries and dates
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Are you currently taking any medications?* This field is required.
YESNO
24
List current medications and dosages
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Are you committed to losing weight?* This field is required.
YESNO
26
Terms and Conditions* This field is required.By agreeing to the terms and conditions, you consent to being contacted through audio, video, and SMS services solely for the purpose of initiating and following up on your weight loss program
27
Appointment* This field is required.
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