Eligibility Screening for Prescribing

1
Full Name* This field is required.
First Name
Last Name
2
Email Address* This field is required.
example@example.com
3
Date of Birth* This field is required.
Date
Year
Month
Day
4
Gender* This field is required.
Female
Male
Prefer not to say
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Address* This field is required.
Street Address
Street Address Line 2
City
State
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
7
Your Height* This field is required.
8
What is your current weight?* This field is required.Insert your total WEIGHT in LBS
9
Your BMICalculated using Weight (Lbs) and Height (inches). Unit: Lbs
10
MOTIVATIONAL: What is your main priority right now?Select Single
Weight Loss
Better appetite control
Better metabolic health
Better energy
Better confidence
Other
11
MOTIVATIONAL: How much weight would you like to lose?Single select
Less than 10 lbs
10-20 lbs
21-40 lbs
41-60 lns
More than 60 lbs
Not sure
12
MOTIVATIONAL: When would you like to reach your goal?Single select
As soon as possible
Within 3 months
Within 6 months
Within 12 months
I am not sure
13
MOTIVATIONAL: What have you tried before to lose weight?Multi-select
Diet and Exercise
Coaching programs
Prescription weight loss medications
Over-the-counter supplements
Bariatric surgery
Nothing yet
14
PRIMARY CARE PHYSICIAN: Are you currently under the care of a primary care doctor?* This field is required.
YESNO
15
LAB WORK: Have you had any blood work done recently? If so, when?* This field is required.Approximate date
Type NONE if never done
16
Take the First Step — GLP-1 Eligibility Check
17
MEDICAL CONDITIONS: Do you currently have any of the following conditions?* This field is required.
Personal or family history of Medullary Thyroid Cancer
MEN2 diagnosis
Currently Pregnant, Undergoing Fertility Treatment or Breast Feeding
Active unstable cardiac symptoms
Active cancer treatment
History of pancreatitis or pancreatic surgery
Active severe abdominal pain/vomiting
Complex cardiac history
Bipolar disorder, Psychosis or Psychiatric hospitalization
Active eating disorder behaviors
Severe kidney or liver disease
None of the Above
18
Upload a Self Photo
19
Upload a photo of your IDeg: Drivers Licence
20
WT LOSS EVALUATION: How active are you?
Very active
Somewhat active
Rarely active
Not Active
21
WT LOSS EVALUATION: How would you describe your eating pattern?
Mostly balanced
Frequent overeating
Frequent cravings
Emotional eating
Irregular meals
Night eating
Other
22
WT LOSS EVALUATION: Which best describes your alcohol use?
Occasional
Weekly
Daily
Heavy or binge drinking
None of the Above
23
WT LOSS EVALUATION: Do you currently smoke or use nicotine?
Occasionally
Daily
Former user
Never
24
WT LOSS EVALUATION: Do you currently restrict food, binge, purge, or misuse laxatives?
Restrict Food
Binge
Purge
Misuse Laxatives
None of the above
25
MEDICATION: Are you on any Weight Loss Medication?* This field is required.
YESNO
26
MEDICATION: List your WEIGHT LOSS Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
27
MEDICATION: Are you on any DIABETES Medication?* This field is required.
YESNO
28
MEDICATION: List your DIABETES Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
29
MEDICATION: Are you on any BLOOD PRESSURE Medication?* This field is required.
YESNO
30
MEDICATION: List your BLOOD PRESSURE Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
31
MEDICATION: Are you on any CHOLESTEROL Medication?* This field is required.
YESNO
32
MEDICATION: List your CHOLESTEROL Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
33
MEDICATION: Are you on any INSULIN Medication?* This field is required.
YESNO
34
MEDICATION: List your INSULIN Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
35
MEDICATION: Are you on any THYROID Medication?* This field is required.
YESNO
36
MEDICATION: List your THYROID Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
37
MEDICATION: Are you on any PSYCHIATRIC Medication?* This field is required.
YESNO
38
MEDICATION: List your PSYCHIATRIC Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
39
MEDICATION: Are you on any SEIZURE Medication?* This field is required.
YESNO
40
MEDICATION: List your SEIZURE Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
41
MEDICATION: Are you on any BIRTH CONTROL Medication?* This field is required.
YESNO
42
MEDICATION: List your BIRTH CONTROL Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
43
MEDICATION: Are you on any OPIOD PAIN Medication?* This field is required.
YESNO
44
MEDICATION: List your OPIOD PAIN Medication* This field is required.NAME, DOSAGE, FREQUENCY AND FOR HOW LONG?
Huge
Large
Normal
Small
Ok
Ok
45
DIABETES: Type 2 Diabetes/Pre-Diabetes* This field is required.
YESNO
46
DIABETES: Have you ever used insulin?* This field is required.
YesNo
47
DIABETES: Any recent low blood sugar episodes?* This field is required.
YesNo
48
DIABETES: What diabetes symptoms / concerns should we know?Please include anything important for your care team.
49
HEART: Heart Disease or Stroke* This field is required.
YesNo
50
HEART: What condition were you diagnosed with?* This field is required.
51
HEART: When was your most recent event?* This field is required.
52
HEART: Are you under active care from a cardiologist?* This field is required.
YESNO
53
HEART: Do you have any implanted cardiac devices, such as Pacemaker, Defibrillator (ICD) or Cardiac Monitor?* This field is required.
YESNO
54
KIDNEY/LIVER: Kidney OR Liver disease?* This field is required.
Kidney Disease
Liver Disease
None of the above
55
KIDNEY/LIVER: Do you know if it is mild, moderate or severe?* This field is required.
Mild
Moderate
None
56
KIDNEY/LIVER: Are you currently being monitored?* This field is required.
YesNo
57
GALL BLADDER: Have you had gallstones or gallbladder removal?* This field is required.
Gallstones removal
Gallbladder removal
None of the above
58
GALL BLADDER: When was the procedure done for Gallstones and/or Gallbladder removal with approximate dates* This field is required.
Huge
Large
Normal
Small
Ok
Ok
59
CANCER: Any Cancer History?* This field is required.
YesNo
60
CANCER: What type of cancer?* This field is required.
61
ALLERGY: Do you have any medication allergies?* This field is required.
YESNO
62
ALLERGY: Select the following medication Allergies* This field is required.
Antibiotics
Pain Relievers / Anti-inflammatories
Insulin
ACE Inhibitors
Allergy to GLP-1 medication class
None of the above
63
SURGERY: Have you had any of the following?* This field is required.Multi-select
Major Surgeries in the last 3 months
Hospitalization in the last 3 months
Bariatric Surgery, such as gastric bypass, sleeve gastrectomy or lap band
Surgeries involving stomach, small intestine or colon
Thyroid Surgery
None of the above
64
SURGERY: List the Surgeries performed in the last 3 months* This field is required.NAME, DOSAGE, FREQUENCY AND WITH APPROXIMATE DATES
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Large
Normal
Small
Ok
Ok
65
SURGERY: List the Hospitalization in the last 3 months* This field is required.REASON AND WITH APPROXIMATE DATES
Huge
Large
Normal
Small
Ok
Ok
66
Acknowlegement of True and Accurate completion* This field is required.By signing below, I acknowledge that I have personally completed and reviewed this medical evaluation form and that all information provided is true, accurate, and complete to the best of my knowledge, I confirm that I have read, understood, and acknowledged all statements, disclosures, consents, policies and terms contained within this form. Our Provider will make an evaluation based on the information provided. By typing my full legal name below and submitting this form constitutes my electronic signature and has the same legal effect as a handwritten signature. I understand that this electronic signature is legally binding.
TYPE FULL LEGAL NAME
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