Ready to take back your health?
Take this short assessment.
Personal Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
e.g. 9179008070
E-mail
*
example@example.com
How did you hear about us?
*
Please Select
Facebook
Instagram
TikTok
Friends/Relatives
Other
Instagram, Facebook or TikTok handle (please indicate what platform:
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e.g. @magebeautystudio - Instagram / MAB Studio - Facebook / @magebeautystudio - TikTok
Whatsapp or Viber Number:
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Please enter a valid viber or whatsapp number.
Let's Calculate your BMI
Please list down your Biological Sex, Height, Weight and BMI.
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Goal Weight?
*
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Safety Screening
Do you or any immediate family member have a history of Medullary Thyroid Carcinoma (MTC)?
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Yes
No
Do you have Multiple Endocrine Neoplasia syndrome type 2 (MEN)?
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Yes
No
Have you ever been diagnosed with pancreatitis or a history of gallbladder issues?
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Yes
No
Diabetes Status
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No Diabetes
Pre-diabetic
Type 2 Diabetes
Type 1 Diabetes
(For Diabetics) Do you have a history of diabetic retinopathy (eye damage)?
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Yes
No
Do you have any history of Kidney Disease or decreased kidney function?
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Yes
No
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General Medical History
Have you ever been diagnosed with, or treated for, the following? (Check all that apply):
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Heart Disease/ Heart Attack? Stroke
High Cholesterol
Sleep Apnea
PCOS (Polycystic Ovary Syndrome)
Gastrointestinal disorders (e.g., Gastroparesis, severe IBS, Crohn's)
Active Cancer or history of cancer (within last 5 years)
Suicidal ideation, severe depression, or history of eating disorders (Anorexia/Bulimia)
Other
Medication & Allergies
List all prescriptions (with dosage), OTC medications, vitamins and supplements (write Not Applicable if NONE):
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Do you have any know allergies to medications (specifically Semaglutide, Tirzepatide, Liraglutide or Retatrutide?
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Are you currently taking any other weight loss medications (Semaglutide, Tirzepatide, Liraglutide, Retatrutide, Phentermine, Contrave, etc).
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Are you currently using insulin or any sulfonylurea medications? YES or NO, please write down the medication if YES.
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Please upload if you have current laboratories result (past 3 months).
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Lifestyle & Social History
How frequent and how much alcoholic drinks do you consume per week?
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Do you smoke or use nicotine products?
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Are you currently pregnant or breastfeeding? (For women, just answer No if you are a man)
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Yes
No
Are you planning to become pregnant in the next 6 months? (For women, just answer No if you are a man)
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Yes
No
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