Welcome

1
Most people complete this in about 2–3 minutes.
This helps us understand your goals and whether GLP-1 treatment may be appropriate to explore.
2
What are you hoping GLP-1 support could help with most?
Lose weight
Reduce cravings or food noise
Fight inflammation
Improve blood sugar or metabolic health
Feel better in my body
Improve energy
Protect my future health
Others..
Other
3
What else could GLP-1 support help with?
4
What is motivating you to look into treatment right now?
Frustration with weight
Cravings feel hard to control
Low energy
Health concerns
Mobility or pain
Upcoming event
Confidence
Something else...
Other
5
What else motivates you to look into treatment now?
6
Body metrics
Height (5.2, 5.8, 6.3)
Current weight (pounds)
Goal weight (pounds)
7
Have you seriously tried to lose weight before?
Yes
No
Not sure
8
What approaches have you tried?
Nutrition changes
Exercise plan
Commercial programs
Dietitian
Intermittent fasting
Low-carb/keto
Weight-loss medication
Bariatric surgery
Others
9
Have you taken a weight-loss medication before?
No
Yes (past)
Currently
10
Which ones?
Semaglutide
Tirzepatide
Liraglutide
Phentermine
Metformin
Other
11
Behavior snapshot
Please Select
Please Select
Yes
No
Sometimes
Frequent cravings?
Please Select
Please Select
Yes
No
Sometimes
Stress or mood affects eating?
Please Select
Please Select
0- Mostly resting
1- Walk and stand
2- Very active 2 days a week
3- Very active 3+ days a week
Activity level
Please Select
Please Select
0- Often get lousy sleep
1- Occasionally a bad sleeper
2- Often get good sleep
3- Always get god sleep
Sleep quality
12
Can you refrigerate medicine?
YESNO
13
Have you had any of the following?
Type 2 diabetes
Prediabetes
PCOS
High blood pressure
High cholesterol
Sleep apnea
Fatty liver
Thyroid disorder
Pancreatitis
Gallbladder disease
Kidney disease
Eating disorder history
None
14
Do you carry any of these diagnoses?
Personal of family history of Thyroid Cancer?
MEN-2 (Multiple Endocrine Neoplasia type 2)
Prior pancreatitis
Severe gastroparesis
Chronic vomiting
Chronic nausea
Pregnant
Trying to conceive
Breastfeeding
I have none of these diagnoses
15
Clinician review is required before recommendations
16
Are you currently taking any of the following?
Insulin
Sulfonylureas
Thyroid medication
Another GLP-1
Alcohol (more than 1 per week)
Cannabis (more than 1 per week)
None
17
Readiness
Please Select
Please Select
Very uncomfortable
A little uncomfortable
Neutral
Comfortable
Very comfortable
Comfort with injections
Biggest concerns? (side effects, cost, long-term use, injections, regaining weight after stopping...)
Please Select
Please Select
1
2
3
4
5
How ready do you feel to proceed?
18
Name
First Name
Last Name
19
Email
example@example.com
20
Phone Number
Please enter a valid phone number.
21
State of Residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
22
Date of birth
Date
Month
Day
Year
23
I understand that submitting this questionnaire does not guarantee treatment. A clinician will review safety, goals, and overall fit before making recommendations.
YESNO
Should be Empty: