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Your Journey to Weight Loss, Simplified
Let's find your personalized path to success with this quick quiz.
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HIPAA
Compliance
1
Do any of the following apply to you?
*
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(Select all that apply)
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2
Let's calculate your BMI
*
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3
BMI Result
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4
What's your weight loss goal? (Pounds/lbs.)
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Please note that while this information is helpful, medical decisions will be made by the clinicians keeping clinical evidence and patient safety at the forefront.
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5
What have you tried in the past to lose weight?
*
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(Select all that apply)
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6
Imagine feeling great every single day. Take a moment to reflect on what achieving your goal weight truly means to you. Select the THREE most important to you.
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7
Are you currently taking or have you taken
GLP-1 medication
for weight loss in the last 12 months?
*
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YES
NO
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8
Are you currently taking or have you taken
any other medications for weight loss
in the last 12 months?
*
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YES
NO
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9
Please list the name, dose, and frequency of your current or recent (within the last 12 months) weight loss medication(s).
*
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10
What was your starting weight in pounds (lbs)?
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11
What is your current weight in pounds (lbs)?
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12
Do you agree to only obtain weight loss medication through this platform moving forward?
*
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YES
NO
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13
When was your last dose of medication? This question is required before further medication can be prescribed.
*
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14
Please upload a picture of your current GLP-1 medication pen or vial.
*
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Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
file type: jpg, jpeg, png or pdf
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15
Do you currently take any other prescription medications
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YES
NO
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16
If so, please include name, dose, and frequency of all your medications.
*
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17
Have you taken any prescription medications to lose weight before (not in the last 12 months)?
*
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YES
NO
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18
If so, please include date range, name, dose, and frequency.
*
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19
Have you used (in the last 3 months), or do you plan to use, any opiate medications or drugs?
*
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YES
NO
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20
If so, please include date range, name, dose, and frequency.
*
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21
Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?
*
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YES
NO
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22
If so, please list all your prior bariatric (weight loss), abdominal, and pelvic surgeries. Please include date range and type of surgery.
*
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23
Which are you willing to do to commit to your success?
*
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(Select all that apply)
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24
How has your weight changed in the last 12 months?
*
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25
Do any of these apply to you?
*
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(Select all that apply)
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26
Have you been diagnosed with Pre-Diabetes or Type 2 Diabetes?
*
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YES
NO
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27
What was your most recent fasting glucose value?
*
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28
What was your most recent hemoglobin A1c (HbA1c) value?
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29
What is your current or average blood pressure range?
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30
What is your current or average resting heart rate range
*
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31
Do you have any medication allergies?
*
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YES
NO
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32
Please list what you're allergic to and the reaction each allergy causes:
*
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33
If you qualify - your weight loss medication will be shipped directly to your address. With these medications, nausea is a common side effect in which your provider will proactively prescribe anti-nausea medication. Please provide a pharmacy you would like this anti-nausea medication sent to - with the name, city, and address (if you have it handy).
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34
Do you have any further information which you would like the doctor to know?
*
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YES
NO
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35
If so, please do not include urgent or emergent medical information here, as this is not reviewed immediately.
*
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36
Your name:
*
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First Name
Last Name
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37
Your phone number:
*
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Please enter a valid phone number.
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38
Your email address:
*
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example@example.com
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39
Gender
*
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(Assigned at Birth)
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40
What state do you live in?
*
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41
What's your date of birth?
*
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-
*must be at least 18 years old
Month
Day
Year
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42
Current Date
-
Date
Month
Day
Year
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43
Age
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44
For Further Evaluation
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45
Disqualified
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46
Status
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47
Final Status
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48
I agree to Trims' Terms & Conditions. By providing my phone number, I agree to receive text messages from Trims.
*
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Privacy Policy
Consent To Telehealth
I agree
I don't agree
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