Weight Loss

1
How Stealth Health WorksA short message from our CMO
2
What is your email address?* This field is required.
example@example.com
3
Medication
4
Dosage Instructions
5
Quantity
6
Repeats
7
Please enter a promo code if you have one (Optional)
8
What's your weight loss goal?
Losing 1-15 lbs
Losing 16-50 lbs
Losing 51+ lbs
Not sure
9
How many different weight loss efforts have you previously attempted?
None, this is my first time trying
1-5
6-10
Countless
10
Do you have any family members who face challenges with their weight or related metabolic conditions (e.g., diabetes)?
YESNO
11
Have any of your family members been diagnosed with the following:
Medullary thyroid cancer
Gastroparesis/bowel obstruction
Pancreatitis
Multiple endocrine neoplasia (MEN) type 2
None
12
How would you describe your levels of daily stress?
Rarely stressed
Occasionally stressed
Constantly stressed
13
Where is your weight primarily distributed?
Stomach/Waist
Hips/thighs
All over
14
Typically, how much sleep do you get each night?
More than 9 hours
7-9 hours
Less than 7 hours
Variable/I struggle with sleep
15
When it comes to cravings, what type of food do you usually go for?
Sweet
Salty
Both
None, I don't have cravings
16
How would you rate your diet over the past month?
Extremely Healthy
Quite healthy
Average
Somewhat unhealthy
17
Which of these describes your typical eating habits?
Eating while multitasking
Snacking under stress
Eating for comfort
Rewarding oneself with food
Frequently dining out
18
How long have you had concerns about your weight?
One month
Few months
One year
More than a year
19
What have you tried to lose weight in the past?
Surgery
Prescription weight loss management
Laxatives/Diuretics
Supplements/Over the counter products
Counselling/Therapy
Dieting
Exercise
Other
None
20
Please specify:
21
Do you have a history of eating disorders?
YESNO
22
If yes, please specify:
23
Do you have any mental health diagnoses?
YESNO
24
If yes, please specify:
25
Do you have a history of cardiovascular disease or heart rhythm disturbances?
YESNO
26
What is your height? (cm)
27
What is your weight? (lbs)
28
What is your target weight? (lbs)
29
How much exercise do you get per week?
Please Select
Please Select
None
1 hour or less
1-3 hours
3 hours or more
30
How much exercise do you get per week?
None
1 hour or less
1-3 hours
3 hours or more
31
Have you had a blood test in the past year?
YESNO
32
Was anything abnormal with the blood test? (Cholesterol, blood sugar, etc.?)
33
Do you have any of these health conditions?
Hypertension
Hypotension
Diabetes Type 1
Diabetes Type 2
Prediabetes
Seizure disorder/epilepsy
Heart attack
Heart disease
Stroke
Mini stroke or TIA
Hyperlipidemia
Angina
Congestive heart failure
Liver issues
Cancer
Glaucoma
Gout
Cystic fibrosis
Hyponatremia
Obstructive sleep apnea
None
34
Do you have any of the following kidney-related issues?
Chronic Kidney Disease (CKD)
Other kidney conditions
Kidney Stones
None
35
Please specify:
36
How often do you consume alcohol?
Please Select
Please Select
Rarely/Never
Sometimes
Frequently
Always
37
How often do you consume alcohol?
Rarely/Never
Sometimes
Frequently
Daily/Always
38
Have you used any of the following substances in the past six months?
Cocaine
Methamphetamine
Opioids
Cannabis
None
39
Do you smoke?
YESNO
40
How often do you smoke? (Packs a week, etc.)
41
Are you using any nicotine replacement products?
YESNO
42
If yes, please explain:
43
Do you have any concerns about potential side effects of weight loss treatments?
Huge
Large
Normal
Small
Ok
Ok
44
Is there anything else you would like to share with the healthcare team?
Huge
Large
Normal
Small
Ok
Ok
45
Full Name* This field is required.
First Name
Last Name
46
Phone Number* This field is required.
47
Date of Birth
Year, Month, Day
48
Biological Sex
Male
Female
Intersex
49
Are you currently pregnant or breast feeding?
YESNO
50
Address
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
51
Allergies?
YESNO
52
What is your allergy?
Huge
Large
Normal
Small
Ok
Ok
53
Are you currently taking any medications, vitamins, herbs, or supplements?
YESNO
54
Please list your medications, vitamins, herbs, and supplements here:(Name, Strength, Regimen)
Huge
Large
Normal
Small
Ok
Ok
55
Do you have any medical conditions?
YESNO
56
Please list your medical conditions here:(Name, How long you've had the condition)
Huge
Large
Normal
Small
Ok
Ok
57
SignatureBy signing below you accept that the above information provided is accurate and truthful. You also acknowledge that a staff member will contact you for ID verification prior to dispensing the prescription.
Powered by Jotform SignClear
Should be Empty: