Nylix Health: Is GLP-1 Support Right for You?
Answer 3 quick questions to see whether medical GLP-1 care may be appropriate. No obligation. All information is kept confidential and reviewed in accordance with medical privacy standards.
What are you most hoping to improve right now?
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Fat loss
Energy/metabolic health
Body composition (fat vs muscle)
Not sure. I just want guidance
Is maintaining muscle/strength important to you?
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Yes
Somewhat
Not a priority
Where can we send your results?
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example@example.com
Name
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First Name
Last Name
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Date of birth
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Month
-
Day
Year
Date
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Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Height (ft/in.)
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Weight (lbs)
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BMI
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What are your primary goals for GLP-1 therapy?
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Weight loss
Appetite control
Improved glucose control
Lower A1c
More stable hunger levels
Other
How long have you struggled with weight or appetite?
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Medical History
Do you have or have you ever been diagnosed with any of the following? (Select all that apply)
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Type 2 Diabetes
Prediabetes
PCOS
High cholesterol
High blood pressure
Sleep apnea
GERD
Kidney disease
Liver disease
Thyroid disease
History of pancreatitis
Gallbladder disease
Depression / Anxiety
None
Have you ever been told you have fatty liver or elevated liver enzymes?
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Yes
No
Not Sure
Any personal or family history of medullary thyroid cancer or MEN2?
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Yes
No
Not Sure
Are you currently pregnant or breastfeeding?
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Yes
No
Do you plan to become pregnant in the next 6 months?
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Yes
No
Medications
List all current medications (prescription, OTC and supplements)
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Are you currently taking any GLP-1 medications?
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No
Semaglutide
Tirzepatide
Other
If you're currently taking any GLP-1 medications which dose are you on?
Have you used weight loss medications in the past?
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Yes
No
If yes, which ones?
Do you have any allergies to medications?
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Yes
No
If yes, which ones?
Lifestyle Factors
How would you describe your eating patterns?
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How many days per week do you exercise?
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What diets or approaches have you tried in the past?
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Safety Questions
Any personal/family history of medullary thyroid carcinoma?
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Yes
No
Not Sure
Any history of pancreatitis?
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Yes
No
Any gallbladder disease?
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Yes
No
Any chronic GI issues?
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Yes
No
Any history of severe hypoglycemia?
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Yes
No
Have you ever been told you have vitamin B6 toxicity, vitamin B12 sensitivity, or peripheral neuropathy?
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Yes
No
Lab Access
Do you have insurance that covers lab work?
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Yes
No
Other
When was your last A1c, CMP, CBC, or lipid panel?
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Telehealth and Medication Consent
I consent to telehealth services and understand that care is provided remotely without an in-person exam, may have limitations, and may require referral to in-person or emergency care.
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Yes
I acknowledge that GLP-1 medications may have side effects including nausea, vomiting, constipation, diarrhea, gallbladder issues, or pancreatitis.
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Yes
I confirm that I have answered all questions truthfully and to the best of my knowledge.
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Yes
I understand medication is prescribed only after clinical review and monthly follow-up is required for refills.
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Yes
If prescribed, I understand my medication may be compounded and is not FDA-approved.
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Yes
I understand this service is not for medical emergencies and that I should call 911 or go to the nearest emergency department if urgent or emergent symptoms occur.
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Yes
I acknowledge receipt of the HIPAA Notice of Privacy Practices and understand how my health information may be used and disclosed.
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Yes
I understand that individual weight-loss results vary and are not guaranteed.
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Yes
I authorize the release of my prescription and relevant health information to the pharmacy selected for dispensing my medication.
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Yes
I understand GLP-1 medications carry a boxed warning related to thyroid C-cell tumors and should not be used in individuals with a personal or family history of medullary thyroid carcinoma (MTC) or MEN2.”
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Yes
I understand that medical services are provided by a California licensed Nurse Practitioner and that provider consultation and follow-up fees are non-refundable once services have been rendered.
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Yes
Signature
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Date
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Month
-
Day
Year
Date
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