Are You Qualified? GLP-1 Quiz
Complete this quick screening to see whether you may be a good fit for GLP-1 treatment. Please answer honestly so the clinical team can review your information.
Basic Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex Assigned at Birth
*
Female
Male
Intersex
Prefer not to say
State of Residence
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Other
Body Metrics and Weight-Loss Goals
Current weight (include unit)
*
Goal weight or amount to lose (include unit)
Primary weight-loss goal
*
Improve health
Fit better in clothes
Increase energy
Support fertility/pregnancy goals
Improve mobility
Prepare for an event
Other
GLP-1 Experience and Interest
Have you used a GLP-1 medication before?
*
Yes
No
Which GLP-1 medication(s) have you used?
Semaglutide
Tirzepatide
Liraglutide
Dulaglutide
Exenatide
Other
Are you interested in learning whether you may qualify for GLP-1 treatment?
*
Yes
No
Maybe
Lifestyle and Weight History
How long have you been struggling with weight management?
*
Please Select
Less than 1 year
1–2 years
3–5 years
More than 5 years
Since childhood/teen years
Prefer not to say
Which of the following have you tried to manage your weight?
Diet changes
Exercise routine
Calories or food tracking
Commercial weight-loss program
Nutritionist or dietitian
Prescription weight-loss medication
Over-the-counter supplements
None of these
Other
If clinically appropriate, would you be comfortable with a prescription-only treatment?
*
Yes
No
Not sure
Medical Screening
Do you have any of the following medical conditions or history?
*
Thyroid cancer or medullary thyroid carcinoma
Multiple endocrine neoplasia type 2 (MEN2)
Pancreatitis
Gallbladder disease
Kidney disease
Liver disease
Diabetic retinopathy
Eating disorder
None of the above
Other
Please provide details about the medical condition(s) you selected
Please list any current medications, supplements, or over-the-counter products you take
If you take diabetes-related medication, please enter the name(s) and dose(s)
Do you have any allergies or medication reactions?
*
Medication allergy
Food allergy
Latex allergy
Other allergy
No known allergies
Could you be pregnant or are you currently breastfeeding?
*
Pregnant
Breastfeeding
Possibly pregnant
Neither
Not applicable
Contact Preferences and Consent
Preferred contact method
*
Phone
Text message
Email
Consent to be contacted by phone, text, or email
*
I agree
Privacy and terms acknowledgement
*
I acknowledge and agree
See If Qualify
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