GLP1 Intake Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
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
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
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
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email* This field is required.
example@example.com
6
Why do you want to use a GLP1?* This field is required.
Weight Loss
Blood sugar management
Inflamation
7
Current Height* This field is required.
Please Select
Please Select
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
8
Current Weight* This field is required.
9
Goal Weight* This field is required.
10
Why do you want to lose weight and what are your weight management goals?* This field is required.
Improve overall health and reduce risk of chronic conditions
Increase energy levels and feel more confident
Achieve a specific weight or body composition goal
Enhance physical fitness and improve athletic performance
11
Have you previously tried to lose weight? If so, what methods have you used?* This field is required.
Yes, I have tried dieting (e.g., calorie restriction, low-carb, etc.)
Yes, I have tried exercising more (e.g., gym, walking, running, etc.)
Yes, I have tried a combination of both diet and exercise
No, I have not tried to lose weight before
12
How active are you on a typical week?* This field is required.
Very active – I exercise 5 or more days a week with intense activity
Moderately active – I exercise 3-4 days a week with moderate activity
Occasionally active – I exercise 1-2 days a week or engage in light activity
Not active – I do not engage in regular exercise or physical activity
13
Are you currently following a specific diet or eating plan?* This field is required.
Yes, I follow a specific diet (e.g., keto, paleo, vegan, intermittent fasting, etc.)
Yes, I try to stick to a general eating plan (e.g., calorie counting, portion control, etc.)
No, but I make an effort to eat healthier or limit certain foods
No, I do not follow any specific diet or eating plan
14
Why do you want to lose weight and what are your weight management goals?
15
Previous attempts at weight loss - please describe
16
Current exercise routine
17
Do you follow a special diet at this time?
18
Have you used any medications to lose weight in the past?
19
Have you ever used medication or supplements to help with weight loss?* This field is required.
Yes, I have used prescription weight loss medication
Yes, I have used over-the-counter weight loss supplements
No, I have never used medication or supplements for weight loss
20
Past Medical History (Check all that pply)* This field is required.
Diabetes
Thyroid
Blood Pressure
Cholesterol
PCOS
Cancer or family history of cancer
Gastroparesis
21
Have you used a GLP1 in the past?* This field is required.
Yes
No
22
What do you know about this class of medications?* This field is required.
Alot
Some
A lIttle
Nothing
23
Are you currently pregnant or breastfeeding?* This field is required.
Yes
No
24
Do you take any supplements? Please list.
25
What state do you live in?* This field is required.
26
Who is your local pharmacy?* This field is required.
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