Medical Intake Form

Medical Intake Form
What is your name*
By continuing, you agree to your health and other data being used by us for this assessment and marketing purposes. This data may be shared with our third-party providers. See Privacy Policy for details

Have you used weight loss medication within the past 3 months?

YesNo
This includes GLP-1s like Wegovy, Mounjaro, or Saxenda, as well as Contrave, Phentermine, or Qsymia.

Which have you tried in the past? (Select all that you've tried.)

DietingExercise plansCoachingWeight loss medicationsOther

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Please enter your legal first and last name as they appear on your driver's license.
Full Name*

First NameLast Name
Email*
example@example.com
Password*

Your medical history

Next, we'll ask some more questions about you and your medical history - just like you'd answer at a doctor's office. This helps our team find the best treatment plan for you.

Have you ever had any of the following? (Choose all that apply)

Type 1 diabetesSeizuresPancreatitisGlaucomaGastroparesisGallbladder diseaseNone of these

Have you ever been diagnosed with bulimia nervosa or anorexia nervosa in the last year?

YesNo

Do you or your parents or siblings have a history of any of these conditions? (Choose all that apply)

Medullary thyroid cancerMultiple endocrine neoplasia type 2None of these

On Average, how much alcohol do you consume per week? (This is helpfull to understand the best treatment options for you)

None1-3 drinks per week4-6 drinks per week7 or more per week

Are you taking any of the following medications? (Choose all that apply)

InsulinSulfonylurea (Ex. Glimepiride, Glipizide, Glyburide)Sulfonylurea (Ex. Repaglinide, Nateglinide, and Mitiglinide)Opioid pain medicationPsychiatric medication (Ex. for anxiety or depression)None of these

Do you have government insurance?

The following list does not include all government insurance plans. Please confirm your plan to see if it is fully or partially funded by the federal government.
- Medicare, Medicare Advantage, Medicare
- Supplement Plans such as Medigap
- Medicaid
- TRICARE (US military healthcare)
- Indian Health Service (IHS)
- State Children's Health Insurance Plan (CHIP)
- AmeriCorps State and National Health Plan
- National Civilian Community Corps Health Plan
- Refugee Medical Assistance Program (RMA)
Do you have government insurance?

Yes, I have government insuranceNo, I do not have government insurance
Should be Empty:

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