Medical Weight-loss Survey

Medical Weight-loss Survey

Please read the responses to questions in the gray boxes to the right when hovering over questions
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
What treatment are you most interested in for Medical weight-loss*

Metabolic Reset (weight management)Hormone OptimizationLab PanelVitamin InjectionsDirect Primary Care MembershipOther
How ready are you to start your medical weight-loss journey?

Very ready, have researched and ready to make this happenActively researching but interestedNot super interested, just seeing if I qualify
Please indicate your age*

0-1718-2121+
What is your BMI range, Calculate to the right*

26.9 and below27-3030 or above
Calculate your BMI
Do you or a blood related family member have a history of medullary thyroid cancer or Multiple Endocrine Neoplasia (MEN) syndrome*

YesNo
Currently breastfeeding, pregnant, or planning to become pregnant?

YesNoWould like to lose weight to be able to conceive
Currently being treated or investigated for cancer?*

YesNo
Do you have an active eating disorder?*

YesNo
Active gallbladder disease?*

YesNo
Active substance abuse or dependency*

YesNo
Type I Diabetes*

YesNo
Bariatric surgery within the past 18 months*

YesNo
Pancreatitis within the past 6 months or a history of pancreatitis caused by taking a GLP-1*

YesNo
If you answered "YES" to any of the above, you may not qualify for treatment. However if you would still like to discuss your goals and medical history please continue to submit this form and it will direct you to a free consult scheduling link.
Are you located in Florida?*

YesNo
Do you have any questions or concerns you would like to describe below?
Why choose our program? We are not just a "weight-loss" clinic. We approach each patient individually in a concierge style environment, working 1-1 to resolve the root cause of the problem causing the obesity!

Metabolic Reset Program Includes
- Medical evaluation and follow up
- Symptom Management
- Nutrition and diet coaching
- Unlimited use of our wellness app and secure chat with Teylar Arroyo APRN, a board certified autonomous nurse practitioner.
- ShapeScale Scan Initial and every 4-8 weeks to track progress
Link to our calendar

Once you schedule, you will be sent an invitation email from our Healthie Application. Please accept the invite and download the app to facilitate your appointments.

Please feel free to contact us if you have any questions or need help!

info@optimumwh.com or 772-206-2028
Should be Empty: