ProviaRx Patient Health Assessment Form
Complete this form to help us understand your health background and treatment preferences.
Which program are you interested in
*
GLP-1 Injectable — Weekly injection (from $179/first month then $279/mo)
GLP-1 Oral Tablet — Daily dissolving tablet ($229/mo)
Hormone/Testosterone Therapy ($99/mo)
Complete Bundle — GLP-1 + Testosterone ($269/mo)
Body Stats
Height
*
Weight
*
Goal Weight (lbs)
BMI (auto-calculated)
Medical History
Serious conditions
End-stage kidney disease (on dialysis)
End-stage liver disease (cirrhosis)
Current suicidal thoughts or prior attempt
Cancer (active, in treatment, or remission under 5 years)
Severe GI condition (gastroparesis, intestinal blockage, IBD)
Alcohol/opioid/substance use disorder
Personal or family history of MTC or MEN2
None of the above
Metabolic conditions
Gallbladder disease
Hypertension
Seizures/epilepsy
Glaucoma
Sleep apnea
Type 2 diabetes (not on insulin)
Type 2 diabetes (on insulin)
Type 1 diabetes
Diabetic retinopathy/optic nerve damage
Use of warfarin (Coumadin)
History of or current pancreatitis
Thyroid cyst/nodule or thyroid cancer history
None of the above
Cardiovascular and other
Gout
High cholesterol or triglycerides
Depression
Head injury
Tumor or infection in brain/spinal cord
Low sodium (hyponatremia)
Liver disease including fatty liver
Kidney disease (not end-stage)
Elevated resting heart rate (tachycardia)
Coronary artery disease or heart attack/stroke in last 2 years
Congestive heart failure
QT prolongation or heart rhythm disorder
Hospitalization within last 1 year
None of the above
Additional conditions
HIV
Acid reflux/GERD
Asthma
Urinary stress incontinence
PCOS
Clinically proven low testosterone
Osteoarthritis
Prostate issues or prostate cancer
Chronic constipation
Prior weight loss surgery (gastric bypass, sleeve, lap band)
None of the above
Medications and Health Details
Currently taking prescription medications?
*
Yes
No
List current medications and dosages
Drug allergies
Blood pressure range
Please Select
Normal
Elevated
High Stage 1
High Stage 2
Crisis
Unknown
Resting heart rate
Please Select
Normal (60-100 bpm)
Under 60 (bradycardia)
60-80 (low normal)
81-100 (high normal)
Over 100 (tachycardia)
Unknown
Have you previously used GLP-1 medications like Ozempic or Wegovy?
Yes GLP-1
Yes different weight loss med
No
Have you tried any structured weight loss programs before?
Yes
No
Symptoms and Goals
Current symptoms
*
Low energy/fatigue
Difficulty losing weight despite diet and exercise
Food cravings/difficulty controlling appetite
Reduced sex drive
Brain fog/difficulty concentrating
Mood changes/irritability
Poor sleep quality
Elevated blood sugar/pre-diabetes
Activity level
*
Please Select
Sedentary
Lightly active
Moderately active
Very active
Extremely active
Treatment priority
*
Affordability
Maximum potency
Delivery preference
*
Injectable
Oral tablet
No preference
Personal health goals
Informed Consent
All information I provided is truthful and accurate — I understand false medical information is a federal offense.
*
I agree
I understand ProviaRx is a technology platform only and does not employ physicians or practice medicine.
*
I agree
I consent to an independent licensed physician reviewing my health information and understand they may decline.
*
I agree
I understand the medications are compounded and not FDA-approved and I acknowledge the risks.
*
I agree
I understand results are not guaranteed and vary by individual.
*
I agree
I agree to the Terms and Conditions, Privacy Policy, and HIPAA Notice of Privacy Practices.
*
I agree
I consent to receive text and email updates about my prescription status.
I agree
Contact Information
Legal note
First name
*
Last name
*
Email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of birth
*
-
Month
-
Day
Year
Date
Sex assigned at birth
*
Male
Female
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
Submit Assessment
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