GLP-1 Program Eligibility Screening (Non-Clinical)

GLP-1 Screening (Non-Clinical)

This brief screening helps determine whether you may proceed to a consultation for GLP-1 therapy. Completion does not guarantee approval or treatment.
Important Notice

This questionnaire is intended for preliminary eligibility screening only.

It does not provide medical advice
It does not establish a doctor-patient relationship
It does not diagnose or treat any condition
Final eligibility and medical decisions are determined only during a consultation with a licensed physician at Caballero Medical Center Ltd.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com

Which best describes your reason for seeking GLP-1 therapy?*

Weight lossWeight loss + metabolic healthBlood sugar controlOther
If Other please state below

Have you tried structured weight-loss efforts before?*

Yes – diet and exerciseYes – medicationsYes – bothNo

Current Medications (Screening Purposes Only): Are you currently taking any of the following medications? (Check all that apply)*

InsulinSulfonylureas (e.g., glipizide, glyburide)Steroids (long-term)Antipsychotic medicationsNone of the above

GLP-1 therapy requires long term lifestyle changes and regular follow-up. Are you willing to participate in monthly check-ins and follow medical guidance?*

YesNo

Which best describes your expectations?*

I understand this is a medical therapy, not a quick fixI expect rapid weight loss without lifestyle changes

I confirm that the information provided is accurate to the best of my knowledge and is submitted for eligibility screening purposes only.*

Yes

You may proceed to the next step.

Based on your responses, you may be eligible for a GLP-1 consultation.

Please schedule a consultation with a licensed physician to review your information and determine final eligibility.

Thank you for completing the eligibility screening.

Your responses require review by a licensed physician before determining eligibility for the GLP-1 program.

Please schedule a consultation so a physician can review your information and discuss appropriate next steps.

GLP-1 Screening (Non-Clinical)