Health Questionnaire

1
What is your name?
First Name
Last Name
2
Which GLP-1 medication are you using?
3
Are you still using this medication?
Yes
No
4
How long have you been using this medication? (Or, if no longer currently using: how long did you use the medication?)
5
What is your total weight loss since starting this medication?
6
What other benefits have you noticed since starting this medication?
7
What side effects, if any, are you experiencing/have experienced?
8
Did your medication provider recommend any nutrition guidance?(Such as protein or fiber requirements per day, calories, etc.)
Please Select
Please Select
Yes
No
Somewhat - guidance was either unclear or incomplete
9
Are you currently following any kind of approach to eating? If so, please describe:For example: grams of protein per day, fiber intake, an eating style such as Keto or Paleo, calorie counting or app tracking, and/or vitamin and supplement use.
10
Did your medication provider discuss potential muscle loss?
Please Select
Please Select
Yes
No
No, but I'm aware from other sources of information
11
The most recent clinical studies suggest 100-125 grams of protein per day to reduce the risk of muscle loss while on a GLP1. How easy/difficult is it for you to get that amount of protein per day?
Please Select
Please Select
I don't get that much protein in
I find it difficult to get that much protein in
It's somewhat doable some days of the week
It's doable most days of the week
I'm able to do this daily/almost daily with ease
12
Would you benefit from a nutrition plan that streamlined and simplified daily protein intake while on your medication?
13
Do you have an approach or plan for post-medication weight maintenance?
Please Select
Please Select
Yes
No
I'm planning to use a maintenance dose of a GLP-1 Medication long term.
14
Would you benefit from a nutrition plan for post-medication weight maintenance?
15
Is there anything else you'd like to share about your GLP-1/weight loss experience?
16
Thank you so much for taking the time to share! If you would like to speak with a Health Coach regarding a nutrition plan, please provide your phone number below. Totally optional, and I promise not to spam you! ;)
Please enter a valid phone number.
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