Eligibility Screening for Prescribing

1
Full Name
First Name
Last Name
2
Email Address
example@example.com
3
Date of Birth* This field is required.
Date
Year
Month
Day
4
Phone Number
Please enter a valid phone number.
5
Address
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
6
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7
MOTIVATIONAL: What do you want to accomplish?Multi-select questions. Atleast 1 required
Lose Weight
Improve my overall health
Improve another health condition
Increase confidence about my appearance
Increase energy for activities I enjoy
Reduce my future health risks
Other
8
What is your main priority right now?Select Single
Weight Loss
Better appetite control
Better metabolic health
Better energy
Better confidence
Other
9
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
10
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
11
What have you tried before?Multi-select
Diet and Exercise
Coaching programs
Prescription weight loss medications
Over-the-counter supplements
Bariatric surgery
Nothing yet
Other
12
Which prescription weight loss medications have you used?
Semaglutide GLP-1
Tirzepatide GLP-1 & GIP
Liraglutide
Phentermine
Contrave
Qsymia
Other
13
If on prescription weight loss medication, provide last dosage strengthexample: Semaglutide 2.4mg
14
Height in InchesInsert your total HEIGHT in INCHES
15
What is your current weight?Lbs
16
BMISelect the appropriate unit
17
Gender
Female
Male
Prefer not to say
18
If approved your preference for the GLP-1 Program
GLP-1 SEMAGLUTIDE
GLP-1 & GIP TIRZEPATIDE
19
LETS SEE IF YOU ARE ELIGIBLE FOR THE GLP-1 PROGRAM
20
MEDICAL CONDITIONS: Do you currently have any of the following metabolic & organ conditions?
Type 2 Diabetes/Pre-Diabetes
Thyroid disorder
PCOS
Sleep apnea
High blood pressure
High cholesterol
GERD/Reflux
Crohn's disease/ulcerative colitis
21
Where are you located?ZIP
22
DIABETES: Type 2 Diabetes/Pre-Diabetes
YESNO
23
Have you had weight loss surgery?Single select
Yes, within the last 12 months
Yes, more than 12 months ago
No
24
DIABETES: Are you taking medication for your Type 2 diabetes?
YesNo
25
DIABETES: Have you ever used insulin?
YesNo
26
DIABETES: Any recent low blood sugar episodes?
YesNo
27
DIABETES: What diabetes symptoms / concerns should we know?Please include anything important for your care team.
28
HEART: Heart Disease or Stroke
YesNo
29
HEART: What condition were you diagnosed with?
30
HEART: When was your most recent event?
31
IF YES, please provide the name of the Cardiologist
32
HEART: Are you under active care from a cardiologist?
YESNO
33
HEART: Are you currently having any unstable cardiac symptoms, chest pain or shortness of breath?S-A
YesNo
34
KIDNEY/LIVER: Kidney OR Liver disease?
Kidney Disease
Liver Disease
35
Was this diagnosed by a clinician?
YesNo
36
KIDNEY/LIVER: Do you know if it is mild, moderate or severe?
Mild
Moderate
Severe
37
KIDNEY/LIVER: Are you currently being monitored?
YesNo
38
Have you ever been diagnosed with pancreatitis?
YesNo
39
Have you had gallstones or gallbladder removal?
Gallstones removal
Gallbladder removal
40
GI DETAILS (3): Do you currently have significant nausea, vomiting, abdominal pain, or constipation?
41
Do you have any severe chronic GI symptoms?
42
THYROID: Do you have any Thyroid disorder?
YesNo
43
THYROID: Are you taking thyroid medication?
YESNO
44
THYROID: Have you ever had thyroid cancer?
YESNO
45
Have you experienced significant weight loss recently (10+ lbs in 1-2 months)
YesNo
46
Do you have any active eating disorder behaviorS-A
YesNo
47
Are you currently in treatment for eating disorder behaviours?
YesNo
48
Do you currently restrict food, binge, purge, or misuse laxatives?
Restrict Food
Binge
Purge
Misuse Laxatives
None of the above
49
CANCER: Any Cancer History?
YesNo
50
CANCER: What type of cancer?
51
Cancer - Are you currently in treatment ?
YesNo
52
Was it thyroid cancer?
YesNo
53
Thyroid Disorder?
YesNo
54
What thyroid condition do you have?
55
CANCER: Have you ever had medullary thyroid cancer?S-A
YesNo
56
CANCER: Has anyone in your family had medullary thyroid cancer?S-A
YesNo
57
Have you ever been told you have MEN2 or Multiple Endocrine Neoplasia syndrome type 2?S-A
YesNo
58
Have you ever had pancreatitis?S-A
YesNo
59
Currently having severe abdominal pain, vomiting, or dehydration?S-A
YesNo
60
PREGNANCY/FERTILITY: Are you currently pregnant?S-A
YesNo
61
PREGNANCY/FERTILITY: Are you trying to become pregnant?S-A
YesNo
62
PREGNANCY/FERTILITY: Are you breast feeding?S-A
YesNo
63
PREGNANCY/FERTILITY: Do you think you may be pregnant?S-A
YesNo
64
MEDICATION: Are you taking any prescription medications now?
YESNO
65
Which types of medications are you currently taking?Multi-select
Diabetes medication
Metformin
Sulfonylureas (glipizide, glyburide, glimepiride etc)
Insulin
Blood pressure medication
Cholesterol medication
Thyroid medication
Steroids
Psychiatric medication
Seizure medication
Birth control / Hormone therapy
Weight Loss medication
Opioid pain medication
Other prescription medication
66
MEDICATION: Which ones are you taking?
67
Any recent medication change?
YESNO
68
Any Insulin use?
YesNo
69
WEIGHTLOSS MEDICATION: Are you currently taking semaglutide, tirzepatide, phentermine, or another weight-loss medication?
70
WEIGHTLOSS MEDICATION: When was your last dose?
71
Short-term or long-term?
Short Term
Long-Term
72
What is it for?
73
Are your symptoms stable?
74
PSYCHIATRIC: Any history of bipolar disorder, psychosis, or hospitalization?
YESNO
75
ALLERGY: Do you have any medication allergies?
YESNO
76
ALLERGY: Select the following medication Allergies
Antibiotics
Pain Relievers / Anti-inflammatories
Insulin
ACE Inhibitors
77
Please list your medication allergies and reaction?
78
Have you had any of the following?Multi-select
Bariatric surgery
Gallbladder removal
Major surgery in the last 3 months
Hospitalization in the last 3 months
None of the above
79
Which best describes your alcohol use?
None
Occasional
Weekly
Daily
Heavy or binge drinking
80
Do you currently smoke or use nicotine?
No
Occasionally
Daily
Former user
81
How active are you?
Very active
Somewhat active
Rarely active
Not Active
82
How would you describe your eating pattern?
Mostly balanced
Frequent overeating
Frequent cravings
Emotional eating
Irregular meals
Night eating
Other
Should be Empty: