Ready to take back your health?
Take this short assessment.
Personal Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
e.g. 9179008070
Format: (000) 000-0000.
E-mail
*
example@example.com
How did you hear about us?
*
Please Select
Facebook
Instagram
TikTok
Threads
Friends/Relatives
Other
Type in YOUR Instagram, Facebook or TikTok handle (please indicate what platform):
*
e.g. @magebeautystudio - Instagram / MAB Studio - Facebook / @magebeautystudio - TikTok
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Please provide your Whatsapp or Viber Number:
*
Please enter a valid viber or whatsapp number.
Format: (000) 000-0000.
Birthday
*
-
Month
-
Day
Year
Date
Let's Calculate your BMI
Please list down your Biological Sex, Height, Age and BMI.
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Current health issues
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Height:
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Start Weight?
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Goal Weight?
*
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Safety Screening
Do you or any immediate family member have a history of Medullary Thyroid Carcinoma (MTC)?
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Yes
No
Do you have Multiple Endocrine Neoplasia syndrome type 2 (MEN)?
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Yes
No
Have you ever been diagnosed with pancreatitis or a history of gallbladder issues?
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Yes
No
Diabetes Status
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No Diabetes
Pre-diabetic
Type 2 Diabetes
Type 1 Diabetes
(For Diabetics) Do you have a history of diabetic retinopathy (eye damage)?
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Yes
No
Do you have any history of Kidney Disease or decreased kidney function?
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Yes
No
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General Medical History
Have you ever been diagnosed with, or treated for, the following? (Check all that apply):
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Heart Disease/ Heart Attack? Stroke
High Cholesterol
Sleep Apnea
PCOS (Polycystic Ovary Syndrome)
Gastrointestinal disorders (e.g., Gastroparesis, severe IBS, Crohn's)
Active Cancer or history of cancer (within last 5 years)
Suicidal ideation, severe depression, or history of eating disorders (Anorexia/Bulimia)
Other
Medication & Allergies
List all prescriptions (with dosage), OTC medications, vitamins and supplements (write Not Applicable if NONE):
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Do you have any know allergies to medications (specifically Semaglutide, Tirzepatide, Liraglutide or Retatrutide?
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Are you currently taking any other weight loss medications (Semaglutide, Tirzepatide, Liraglutide, Retatrutide, Phentermine, Contrave, etc).
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Are you currently using insulin or any sulfonylurea medications? YES or NO, please write down the medication if YES.
*
Please upload if you have current laboratories result (past 3 months).
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Lifestyle & Social History
How frequent and how much alcoholic drinks do you consume per week?
*
Do you smoke or use nicotine products?
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Are you currently pregnant or breastfeeding? (For women, just answer No if you are a man)
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Yes
No
Are you planning to become pregnant in the next 6 months? (For women, just answer No if you are a man)
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Yes
No
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What are your primary health goals?
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Do you have any dietary restrictions or allergies?
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What is your primary motivation for seeking health improvement?
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Active lifestyle?
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Sedentary
Lightly active
Moderately active
Very active
Which best describes your daily activity level outside of intentional exercise?
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Highly Active (heavy physical labor or constant movement)
Active (on my feet for a good portion of the day)
Lightly Active (mostly sitting, but with regular movement breaks)
Sedentary (vast majority of the day sitting with very little movement)
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Do you currently participate in intentional, structured exercise?
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Yes, consistently (3+ times a week)
Yes, occasionally (1-2 times a week)
Rarely / Not currently
What types of exercise do you do?
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Cardiovascular (walking, running, cycling, swimming)
Resistance / Strength Training (weightlifting, Pilates, bands)
Flexibility / Mobility (yoga, stretching)
High-Intensity Interval Training (HIIT)
Other
On average, how many minutes per week do you spend exercising?
*
Please Select
Under 60 minutes
60 - 150 minutes
150 - 300 minutes
300+ minutes
On an average weekday, approximately how many hours do you spend sitting or reclining (excluding sleep)?
*
Please Select
Less than 4 hours
4 - 7 hours
8 - 11 hours
12+ hours
What is your primary barrier to being more physically active right now?
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Lack of time
Fatigue / Low energy
Joint pain or physical limitations
Lack of motivation / Unsure where to start
Currently recovering from an injury
No barriers, I am happy with my current activity level
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Are you ready to take the next step toward your health and transformation?
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Yes!
No.
How would you prefer us to reach you?
*
Please Select
Call you on your CP number
Call via Whatsapp
Call via Viber
Chat via Whatsapp
Chat via Viber
How would you like to begin your program?
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In-Clinic Experience. Starts at 3,500 per 2.5mg of Tirzepatide shot.
Private Home Kit - Starts at 5,500 per 10ml vial of Tirzepatide.
Private Home Kit - Starts at 6,800 per 10ml vial of Retatrutide.
In-Clinic Experience. Starts at 4,000 per 2mg of Retatrutide Shot.
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