Stat Health Medical GLP-1 Pre-Qualification Form

Stat Health Medical GLP-1 Pre-Qualification Form

(Medical Weight Loss Screening)
BASIC INFORMATION
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

CityState

Zip Code
WEIGHT & ELIGIBILITY
Height (inches)*
Current Weight (lbs)*
Goal Weight (lbs)*
Less than 6 months6–12 monthsMore than 1 year
YesNo
Weight lossAppetite controlBlood sugar controlEnergy improvementOther
MEDICAL HISTORY
Type 2 DiabetesPrediabetesHigh Blood PressureHigh CholesterolSleep ApneaPCOSFatty Liver DiseaseNone
SAFETY SCREENING
PancreatitisGallbladder diseaseSevere gastrointestinal diseaseThyroid cancerFamily history of medullary thyroid carcinomaMultiple Endocrine Neoplasia Syndrome type 2 (MEN2)None
MEDICATION HISTORY
OzempicWegovyMounjaroZepboundSaxendaCompounded semaglutideNone
YesNo
Side effectsCostPlateauProvider discontinuedOther
LIFESTYLE QUESTIONS
None1–2 days3–4 days5+ days
Sugar cravingsLate night eatingEmotional eatingPortion control difficultySlow metabolism
Less than 32 oz32–64 oz64+ oz
Constant hungerSlow metabolismHormonal imbalanceStress or lack of timeNothing works anymore
FEMALE HEALTH SCREENING
YesNo
YesNo
YesNo
TELEHEALTH CONSENT
Pre-Approval Result
Should be Empty: