Qualification Quiz

1

Name* This field is required.

First Name

Last Name

2

Email

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Are you at least 18 years old?* This field is required.

YESNO

5

Are you pregnant, breastfeeding, or planning to become pregnant?* This field is required.

YESNO

6

What is your biological sex?* This field is required.

Male

Female

Other

Prefer Not To Say

7

What is your height?* This field is required.

8

What is your current weight (in pounds)?

9

Do you have any of the following conditions?* This field is required.Select all that apply

High blood pressure

Type 2 diabetes

Sleep apnea

High cholesterol

N/A

10

Have you been diagnosed with Type 1 diabetes?* This field is required.

YESNO

11

Have you had an eating disorder in the past 12 months?* This field is required.

YESNO

12

Do you have a family or personal history of thyroid cancer or MEN2?* This field is required.

YESNO

13

Are you ready to commit to bi-weekly or monthly check-ins and a specialized weight loss treatment?

YESNO

14

BMI Calculation