Nutree Clinic - Weight Loss Eligibility

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Let's calculate your Body Mass Index
Height (feet)*
feet
(inches)*
inches
Weight (in lbs)*
BMI
height in inches

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Name*

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What sex were you assigned at birth?*

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Are you...?*

Pregnant or trying to get pregnantBreastfeedingNone of the above
Have you given birth in the past six months?*

YesNo
What is the date of your last menstrual period?*

MonthDayYear
Date

Personal information
What is your date of birth?*

MonthDayYear
Date of birth

Tell us about your health
Have you or a blood relative ever been diagnosed with any of these conditions?*

Medullary thyroid cancerMEN 2 (Multiple endocrine neoplasia syndrome type-2)None of the above

Tell us about your health
Have you ever been diagnosed with any of the following conditions?*

PancreatitisEnd stage kidney diseaseLong QT syndromeGastroparesisSevere liver disease/cirrhosisNone of the above

Tell us about your health
Are you currently under Medical Care (including any condition you are managing with drugs) ?*

YesNo
Please detail your Medical Care*
e.g. Yes I have Hypothyroidism and I take Levothyroxine

Tell us about your health
Have you had any surgeries or medical procedures (including but not limited to Bariatric surgery)?*

YesNo
Please list procedure, reason, and date below*

Tell us about your health
Have you ever experienced an eating disorder such as: vomiting in order to lose weight, binge eating, or severely limiting your food intake for fear of gaining weight?*

YesNo
Please explain briefly which eating disorders you experienced*

Tell us about your health condition
Have you ever been diagnosed with a mental health condition?*

YesNo
If you have you ever been diagnosed with a mental health condition, please explain*

We have to ask...
Do you currently have any desire to harm yourself or others?*

YesNo
We care about your safety. If you’re feeling at risk of harming yourself or others, Nutree Clinic can’t provide care in this situation.
Please seek immediate help:
- Call 911 (or your local emergency number), or
- Call or text 988 (U.S. Suicide & Crisis Lifeline, 24/7)
If you’re outside the U.S., contact local emergency services or go to the nearest emergency room.

You’re not alone—help is available right now.

Tell us about your lifestyle and habits
Rate your current exercise level:*

1 - Sedentary2 - Light3 - Moderate4 - Active

Tell us about your weight loss journey(s)
GLP-1s medications can include compounded semaglutide, compounded tirzepatide, Ozempic, Wegovy, Mounjaro, and Zepbound.
Are you currently on or have you ever taken a GLP-1 medication?*

I am currently taking a GLP-1 medicationI am a former user of GLP-1 medicationNo, I have never taken a GLP-1 medication
When was your last GLP-1 dose?

MonthDayYear
Date
If you have taken GIP/GLP-1 medications before, please specify which ones and what was the outcome? (oral/injectable, which medication, highest dose...)*
e.g. Ozempic, 1.5mg, lost 25lbs in 4 months

Tell us about your weight loss journey(s)
Have you ever stopped a GLP-1 weight loss program before reaching your goal? If so, why?

I wasn’t seeing results fast enoughI couldn’t stick with itIt became too expensiveI experienced nausea and/or vomitingI experienced constipation and/or diarrheaLife got in the way (stress, travel, family obligations)No, I’m usually consistentOther

Tell us about your weight loss journey(s)
Tell us which diets, other weight loss programs or medications (e.g. phentermine) you have previously tried.*

Tell us about your weight loss journey(s)
Because muscle loss is common with GLP-1, telling us about your experience may help us adjust your care to better support muscle preservation.
Have you experienced muscle loss while taking GLP-1 (Mounjaro, Zepbound, Ozempic, Wegovy, Rybelsus or compounded semaglutide or tirzepatide)?

YesNo

Medication Transition Confirmation
If you’re prescribed a GLP-1 medication by a Nutree Clinic provider, do you agree to stop taking your current weight loss medication?

Yes, I agree to stop taking my current weight loss medication and will inform the provider who prescribed me this before doing soNo, I prefer to continue my current weight loss medication outside of the Nutree Clinic platform
Important safety note
For your safety, we cannot prescribe or manage a GLP-1 medication if you are continuing another GLP-1 treatment (such as tirzepatide) outside of Nutree Clinic. Using multiple GLP-1 medications at the same time can increase the risk of side effects and is not medically appropriate. To move forward with care through Nutree, you’ll need to confirm that you will discontinue your current GLP-1 medication and coordinate this change with the clinician who originally prescribed it. This ensures your treatment remains safe, effective, and properly supervised.

Weight loss medications - injectable
Most FDA-approved medical weight-loss treatments are administered by injection, as this method allows for more consistent and predictable absorption compared to oral options, with less variability between individuals.
While injections can sound intimidating, most patients report that the experience is far more comfortable than expected, often describing little to no discomfort. Your provider will guide you through proper technique and support you at every step.
I have physical or mental factors that would make injecting myself difficult, even with training.

YesNo

Weight loss medications - oral
Hurray! FDA-approved ORAL GLP-1s are now available!

These pills require morning fasting for at least 30 minutes, including water, medications, or supplements.

Because effectiveness depends on a strict routine this option may not be practical for everyone.

When strict adherence is difficult due to schedule or medications, other options — including injectables or personalized compounded oral formulations — may be more appropriate.
Would you be able to consistently follow a strict daily medication routine?*

Yes — I can reliably take a medication every morning while fasting, with no food, drinks, medications, or supplements for at least 30 minutesNo — this would be impractical with my routine and/or medication scheduleI am not sure

Let's talk about common early side effects
A Nutree Clinic licensed provider may be able to help you manage side effects with a personalized treatment plan.
Do you ever experience any of these gastrointestinal symptoms?

NauseaVomitingDiarrheaConstipationAbdominal pain or crampingBloating or excessive gasAcid reflux or heartburnDifficulty swallowingLoss of appetite

Personalized dosing can help manage side effects
Clinical research shows that gradual GLP-1 dose adjustments can help reduce side effects and improve adherence to treatment while maintaining results.*

Nutree Clinic providers consider your medical history and tolerance every step of the way. If appropriate, personalized dosing — rather than a one-size-fits-all approach — may be used to support continued treatment.

Most side effects are mild to moderate and often improve as the body adapts.

*Diabetes Care, 2025 — “Gradual Titration of Semaglutide Results in Better Treatment Adherence and Fewer Adverse Events.”

Let's talk about common early side effects
Would you be interested in your provider considering a personalized dosage plan that can help manage gastrointestinal side effects like nausea, vomiting, constipation, and diarrhea?

YesNo

Let's talk about common early side effects
How disruptive would nausea, vomiting, constipation, and/or diarrhea be to your daily life?

Very disruptiveModerately disruptiveNot disruptive at all

Let's talk about common early side effects
Because fatigue can occur with GLP-1 treatment—especially after larger dose increases—personalized dosing may help improve tolerability.
Would you be interested in your provider considering a personalized dosage plan that can help manage side effects like fatigue and energy loss?

YesNo

Let's talk about common early side effects
How disruptive would fatigue and energy loss be to your daily life?

Very disruptiveModerately disruptiveNot disruptive at all

Let's talk about muscle health during weight loss
Supporting muscle mass helps protect strength, metabolism, and long-term health.

Weight loss — especially when it happens quickly — can be associated with decrease in muscle mass. This is a well-recognized body response, not a failure on your part.

Adequate protein intake and resistance-based movement are commonly recommended to help support muscle preservation.

Nutree Clinic providers consider muscle health as part of your overall treatment plan and may offer guidance on lifestyle strategies and personalized dosing tailored to your needs.

Let's talk about muscle health during weight loss
Would you be interested in your provider considering a personalized dosage plan that can help manage side effects like muscle loss?

YesNo

Let's talk about muscle health during weight loss
How disruptive would muscle loss be to your daily life?

Very disruptiveModerately disruptiveNot disruptive at all

What are your goals and challenges?
What are your weight loss goals (e.g. lose 50 lbs, drop by 3 sizes)?*

What are your goals and challenges?
Are you interested in other wellness goals?*

Retain lean muscleIncrease energyLongevityImprove SleepPersonalized skincareHair regrowthNone of the above

Last question!
How did you hear about us?*

WebsiteAdReferring ProviderClient ReferralOtherCommunity
Should be Empty:

	myself	a relative
Diabetes
Pre-Diabetes
Bowel disease
High blood pressure
High cholesterol
Fatty liver
Kidney disease
Liver disease
Heart disease
Stroke
PCOS
Sleep Apnea
Other chronic / autoimmune / severe disease
None of the above

	Never	Monthly	Weekly	Daily
Alcohol
Tobacco/Nicotine
Recreational substances (e.g. Cannabis, Stimulants)

Let's calculate your Body Mass Index

Personal information

Personal information

Personal information

Personal information

Tell us about your health

Tell us about your health

Tell us about your health

Tell us about your health

Tell us about your health

Tell us about your health

Tell us about your health condition

We have to ask...

Tell us about your lifestyle and habits

Tell us about your lifestyle and habits

Tell us about your weight loss journey(s)

Tell us about your weight loss journey(s)

Tell us about your weight loss journey(s)

Tell us about your weight loss journey(s)

Tell us about your weight loss journey(s)

Medication Transition Confirmation

Weight loss medications - injectable

Weight loss medications - oral

Let's talk about common early side effects

Personalized dosing can help manage side effects

Let's talk about common early side effects

Let's talk about common early side effects

Let's talk about common early side effects

Let's talk about common early side effects

Let's talk about muscle health during weight loss

Let's talk about muscle health during weight loss

Let's talk about muscle health during weight loss

What are your goals and challenges?

What are your goals and challenges?

Last question!