• Stat Health Medical GLP-1 Pre-Qualification Form

    (Medical Weight Loss Screening)

  • BASIC INFORMATION

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • WEIGHT & ELIGIBILITY

  • How long have you been trying to lose weight?*
  • Have you tried diet and exercise without success?*
  • What is your primary goal for treatment?*

  • MEDICAL HISTORY

  • Have you ever been diagnosed with:*

  • SAFETY SCREENING

  • Do you currently have or have you ever had:*

  • MEDICATION HISTORY

  • Are you currently taking any of the following?*
  • Have you previously used a GLP-1 medication?*
  • If yes, why did you stop?*

  • LIFESTYLE QUESTIONS

  • How many days per week do you exercise?*
  • Do you experience:
  • Average daily water intake:*
  • What is the biggest thing holding you back from losing weight right now?*

  • FEMALE HEALTH SCREENING

  • Are you currently pregnant?*
  • Are you breastfeeding?*
  • Are you planning pregnancy in the next 6 months?*

  • TELEHEALTH CONSENT

  • Should be Empty: