Type3 Health Intake Form

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What is your first name?First Name
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What is your last name?Last Name
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Email
example@example.com
4
Were you referred by your employer or a member organization you belong to?
YesNo
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Great! Please provide the name of the organization that referred you here:
6
Do any of the following apply to you?Please check all that apply -or- check None of the below.
None of the below
Currently or possibly pregnant, or actively trying to become pregnant
Breastfeeding or bottle-feeding with breastmilk
End-stage kidney disease (on or about to be on dialysis)
End-stage liver disease (cirrhosis)
Current or prior eating disorder
Current suicidal thoughts and/or prior suicidal attempt
Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years; does not apply to non-melanoma skin cancer that was considered cured via simple excision alone)
History of organ transplant on anti-rejection medication
Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)
Type 2 diabetes (on insulin)
Type 1 diabetes
Diabetic retinopathy (diabetic eye disease)
History of or current pancreatitis
Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2
7
Are you currently taking or have recently (within the last 12 months) taken medication(s) for weight loss?
Yes, I currently take or have recently (within the last 12 months) taken a GLP-1 medication for weight loss
Yes, I currently take or have recently (within the last 12 months) taken another medication for weight loss
No
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Do you agree to only obtain weight loss medication through this platform moving forward?
YesNO
9
Please enter your height and weight.
Feet
Inches
What is your current weight?
Heigh in Total Inches
height Meters
BMI
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Feet
height_ft
11
Inches
height_in
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Please enter your weight
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BMI
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What is your age range?
Less than 18 years old
18 - 74 years old
75 years old +
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Would you like information about our weight management program that does not include GLP-1 Prescriptions?We'll provide you with monthly updates on programs as they become available.
YESNO
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Thank you for your time. We'll email you information about our additional programs or visit type3health.com for updates.
17
Sign up to Learn MorePlease provide your email address so we can notify you of additional medically guided programs.
First
Last
Please enter your email
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Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
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
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State(Some states require that we provide a telehealth consult with a licensed clinician before your first prescription.)
Please Select
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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Phone Number
Please enter a valid phone number.
21
Today's Date
Date
Month
Day
Year
22
Age
23
Date of Birth
Date
Month
Day
Year
24
What was your sex assigned at birth?NOTE TO FEMALE PATIENTS OF REPRODUCTIVE POTENTIAL IF ‘NONE OF THE ABOVE’ IS SELECTED - Please note that we strongly recommend that you use an effective method of contraception during treatment with a GLP-1 medication and for at least 2 months thereafter. For those taking Zepbound or Mounjaro (tirzepatide), we recommend switching to a non-oral contraceptive method or adding a barrier method of contraception for four weeks after initiation and for four weeks after each dose escalation.
MaleFemale
25
What is your Race or Ethnicity?
Please Select
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other pacific Islander
White
26
Please list the name, dose, and frequency of your current or recent (within the last 12 months) weight loss medication(s)In a previous question - you responded that you were currently or have recently taken a GLP-1 or other weight loss medication for weight loss
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Large
Normal
Small
Ok
Ok
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What was your starting weight in pounds (lbs)?
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What is your current weight in pounds (lbs)?
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When was your last dose of medication?
0-5 days
11-14 days
6-10 days
More than 2 weeks ago but within the last 4 weeks
More than 4 weeks ago
30
Please provide a clear picture of the prescription with your name, date of birth, medication, and dosing instructions on it.Please upload a picture of your current GLP-1 medication pen or vial.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Do you currently take any medications?
YESNO
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Please include name, dose, and frequency of all your medications
Huge
Large
Normal
Small
Ok
Ok
33
Have you taken any prescription medications to lose weight before?
YESNO
34
Please include date range, name, dose, and frequency
Huge
Large
Normal
Small
Ok
Ok
35
Are you currently taking, plan to take, or have recently (within the last 3 months) taken opiate pain medications and/or opiate-based street drugs?
YESNO
36
Please include date range, name, dose, and frequency
Huge
Large
Normal
Small
Ok
Ok
37
Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?
YESNO
38
Please list all your prior bariatric (weight loss), abdominal, and pelvic surgeries. Please include date range and type of surgery
Huge
Large
Normal
Small
Ok
Ok
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Have you ever attempted to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification?
YESNO
40
Please provide brief details of your attempt to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification
Huge
Large
Normal
Small
Ok
Ok
41
Are you willing to:
Reduce your caloric intake alongside medication, if clinically appropriate
Increase your physical activity alongside medication, if clinically appropriate
None of the above
42
How has your weight changed in the last 12 months?
Lost a significant amount
Lost a little
About the same
Gained a little
Gained a significant amount
43
Do any of these apply to you?
Gallbladder disease
Drug or alcohol misuse
Hypertension (high blood pressure)
Uncontrolled blood pressure (above 160/100 mmHg)
Seizures
Glaucoma
Sleep apnea
Type 2 diabetes (not on insulin)
Type 2 diabetes (on insulin)
Type 1 diabetes
Diabetic retinopathy (eye condition related to diabetes)
History of or current pancreatitis
Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2
Gout
High cholesterol
High triglycerides
Depression
Head injury
Tumor or infection in your brain or spinal cord
Low sodium
Liver disease, including nonalcoholic fatty liver disease (NAFLD)
Kidney disease
Elevated resting heart rate or a diagnosis of tachycardia
Coronary artery disease, recent (last 24 months) heart attack, or stroke
History of congestive heart failure
Recent hospitalization within the last 12 months
Diagnosed with the human immunodeficiency virus (HIV)
Acid reflux/gastroesophageal reflux disease (GERD)
Asthma/reactive airway disease
Urinary stress incontinence
Polycystic ovarian syndrome (PCOS)
Clinically proven low testosterone (male hypogonadism)
Osteoarthritis
None of the above
44
Please provide the details regarding the tumor or infection in your brain or spinal cord.*
Huge
Large
Normal
Small
Ok
Ok
45
Please provide the details regarding liver disease, including nonalcoholic fatty liver disease (NAFLD).*
Huge
Large
Normal
Small
Ok
Ok
46
Have you been diagnosed with prediabetes or type 2 diabetes?
YESNO
47
What was your most recent fasting glucose value?
48
What was your most recent hemoglobin A1c (HbA1c) value?
49
What is your current or average blood pressure range?
<120/80 (Normal)
120-129/<80 (Elevated)
130-139/80-89 (High Stage 1)
≥140/90 (High Stage 2)
50
What is your current or average resting heart rate range?
<60 beats per minute (Slow)
60-100 beats per minute (Normal)
101-110 beats per minute (Slightly Fast)
>110 beats per minute (Fast)
51
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: What is your goal weight or body mass index (BMI)?
52
Do you have any medication allergies?
YESNO
53
Please list your medication allergies and your reaction(s)
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Ok
Ok
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Please list the name and address of your current pharmacy. When prescribing GLP-1 medications, your clinician may prescribe anti-nausea medication to your local pharmacy to assist with side-effects.
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Ok
Ok
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Do you have any further information which you would like the clinician to know?Please do not include urgent or emergency medical information here, as this is not reviewed immediately.
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Ok
Ok
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Membership OptionsPlease select an option to get started.
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Medical Weight Loss With Oral Compounded Tirzepatide
for each month
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Medical Weight Loss With Oral Compounded Semaglutide
for each month
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First Name
Last Name
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Shipping Address Line 1
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Shipping Address Line 2
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Shipping City
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Shipping State(Some states require that we provide a telehealth consult with a licensed clinician before your first prescription.)
Please Select
Please Select
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
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TN
TX
UT
VT
VA
WA
WV
WI
WY
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Your weight loss journey begins today.

Welcome to Type3's Medical Weight Loss Management program.

Check your email for registration to your patient portal.

Please click NEXT below to schedule your initial appointment with one of our clinicians.
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