• Are GLP-1 Medications Right For Me?

• What is your Gender
  MaleFemaleNon-Binary
• Age
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• Height and Weight

• Height

• Feet
• Inches
• Weight (lbs)
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• Health Insurance

• Where do you get your health insurance?
  Through mine or my spouse's employerTRICAREI purchase it individual though the marketplaceThrough a state funded plan (Medicaid, AHCCCS, etc)I have a Medicare or Medicare Advantage plan
• Who is your health insurance carrier?
  Please Select BlueCross BlueShield Cigna Aetna United Healthcare Humana Other
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• Diabetes

• Do You Have Diabetes?
  NoI have Pre-Diabetes (HgbA1c between 5.7% and 6.5%)Yes (HgbA1c>6.5%)
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• GLP-1 Medications

• Ozempic Wegovy Rybelsus  Trulicity Saxenda Victoza

  Mounjaro Zepbound Tanzeum  Byetta  Bydureon  Adlyxin

• Do you currently take any of the medications listed above?
  YesNo
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• What's important to you?

• Check the two statements that you most identify with
  I struggle with portion controlI am a stress or emotional eaterI eat well, but the weight is not coming offI don't eat much, but I frequently make the wrong choices
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• Medication Cost

• What is a monthly budget that you could comfortably afford for GLP-1 medications?
  <$100/month$100-$200/month$200-$400/month>$400/month
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• Long Term Use of Medications

• Are you willing to take medications for weight loss for the long term (>5 years or more)?
  YesMaybe, if they work wellNo, I don't want to be on medications long-term for weight loss
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• Personal or Family History

• Have you ever had an episode of pancreatitis that required medical intervention in the past?
  YesNo
• Do you have a family history of Medullary Thyroid Cancer (other thyroid cancers like papillary or follicular aren't relevant)
  YesNo
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• Get Your Results!

  Check your email after you complete the quiz
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• Last Name
• Email*
• Phone Number
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• Let us know what you're interested in

• I'm Interested in:
  The BooksNutritional CounselingGLP-1 MedicationsBariatric Surgery Consultation
• Please have someone from the Pound of Cure team contact me with more information
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