Nylix Health Eligibility Assessment
This intake is used to determine medical eligibility and safety. No obligation to proceed. All information is kept confidential and reviewed in accordance with medical privacy standards.
How much weight do you want to lose?
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10-20 lbs
20-40 lbs
> 40 lbs
Is maintaining muscle/strength important to you?
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Yes
No
Where should we send your personalized eligibility 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.
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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
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
*
Date
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-
Month
-
Day
Year
Date
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