Wellness Firm - Weight Loss Checklist

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

4

Gender* This field is required.Please select a gender to show symptoms

Male

Female

5

Have you experienced nausea (feeling queasy or sick to your stomach)?* This field is required.

Never

Mild

Moderate

Severe

6

Have you experienced vomiting (throwing up)?* This field is required.

Never

Mild

Moderate

Severe

7

What is your current height?* This field is required.

8

What is your current weight?* This field is required.

9

Do you have a personal or family history of medullary thyroid carcinoma (MTC)* This field is required.

Yes

No

Unknown

10

Do you have a personal or family history of multiple endocrine neoplasia syndrome type 2 (MEN 2)* This field is required.

Yes

No

Unknown

11

Have you ever been diagnosed with pancreatitis, gallbladder disease, or kidney problems?* This field is required.

Yes

No

Unknown

12

Do you have a history of gastrointestinal disorders (e.g., gastroparesis or severe reflux)?* This field is required.

Yes

No

Unknown

13

Do you have any history of eating disorders (e.g., anorexia or bulimia)?* This field is required.

Yes

No

Unknown

14

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

Yes

No

Unknown

15

Do you have any weight-related health conditions, such as type 2 diabetes, high blood pressure, high cholesterol, heart disease, sleep apnea, or joint pain?* This field is required.

Yes

No

Unknown

16

Do you experience fatigue, low energy, or mood changes related to your weight?* This field is required.

Yes

No

Unknown

17

Have you been diagnosed with thyroid issues or cancer?* This field is required.

Yes

No

Unknown

18

Have you tried other weight loss methods (e.g., diet, exercise, surgery) in the past?* This field is required.

Yes

No

19

What are your weight loss goals (e.g., target weight, timeline)?* This field is required.

20

On a scale of 1-10, how motivated are you to make lifestyle changes like improving diet or increasing exercise? (This supports long-term success.)* This field is required.

21

Do you have any concerns about potential side effects, cost, or long-term use? (Our compounded options provide an accessible alternative without insurance hurdles.)* This field is required.