Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
How long have you been on the GLP-1 medication?
*
Have you watched our video on how to properly use your medication?
*
Yes
No
Are you confident that you are using the medication properly?
*
Yes
No
Are you noticing any appetite suppression?
*
Yes
No
What side effects are you experiencing?
*
Have you had any weight loss?
*
Yes
No
If so, how much?
On a scale of 1-5, how satisfied are you with this program?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
On a scale of 1-5, how adherent have you been with taking your GLP-1 medication as directed?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
On a scale of 1-5, how consistent have you been with a workout program and healthier diet?
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Please indicate the severity of each side effect by selecting one of the following options: None, Mild, Moderate, or Severe.
*
Rows
None
Mild
Moderate
Severe
Nausea
Diarrhea
Vomiting
Constipation
Abdominal Pain
Headache
Fatigue
Indigestion
Dizziness
Bloating
Belching
Gas (Flatulence)
Other concerns
Please verify that you are human
*
Submit
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