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Semaglutide assessment form
Step
1
of
10
10%
Name
(Required)
First
Last
Date of Birth
(Required)
Sex
(Required)
Male
Female
Phone Number
(Required)
Email Address
(Required)
Are you here to be evaluated for weight loss?
(Required)
Yes
No
Do you have any of the following medical problems?
(Required)
Cirrhosis/liver disease
End stage renal failure
None of the above
Do you have any of the following medical problems?
(Required)
High cholesterol
Obstructive sleep apnea
Type 1 diabetes
Type 2 diabetes
Ha1C above 5.7
None of the above
Have you ever attempted to lose weight through a weight management program longer than 6 months?
(Required)
Yes
No
Are you willing to reduce your caloric intake alongside medication?
(Required)
Yes
No
Are you willing to increase your physical activity alongside medication?
(Required)
Yes
No
Have you ever dealt with following:
(Required)
Anorexia nervosa
Bulimia nervosa
None of the above
Do you have any of the following?
(Required)
History of chronic pancreatitis or previous episode of pancreatitis due to GLP-1
History of severe gastrointestinal disease
History of diabetic retinopathy or other retinopathy
History of medullary thyroid cancer
History of Bariatric surgery within past 6 months
History of MEN-2 (multiple endocrine neoplasia type 2)
History of gallbladder disease (excluding history of gallbladder removal/cholecystectomy)
Diabetes
None of the above
Does anyone in your Family have a history of:
(Required)
MEN-2 (multiple endocrine neoplasia type 2)
Medullary thyroid cancer
None of the above
Are you taking any medications?
(Required)
Yes
No
Current Medications:
(Required)
Please list the generic name of your medication, the dose, how many times per day, how long you have been on this medication.
Did you ever have any type of thyroid cancer?
(Required)
Yes
No
Please type the thyroid cancer type/s you have or had?
(Required)
Do you have any allergies to medications?
(Required)
Yes
No
List your medication allergies
(Required)
What is your goal weight?
(Required)
Current Weight (lb)
(Required)
Height
(Required)
Disclaimer
(Required)
According to the American Board of Obesity Medicine (ABOM) patients who have a BMI between 27-30 may qualify for medical assisted weight loss based on other medical conditions they may have. Patients below BMI of 27 are not ABOM candidates.
Link to BMI calculator:
https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
If your prescribing doctor doesn’t feel you qualify, support will provide you a refund within 4 business days.
I Agree
Please provide a recent blood pressure measurement within the last 6 months, which should be listed as follows: Systolic (top number)/Diastolic (bottom number)
(Required)
If you are not sure, please go have your blood pressure obtained (typically free at your local pharmacy).
Are you pregnant or expecting to be?
(Required)
Pregnant
Breastfeeding or lactating
Expecting to be pregnant
No or Doesn’t apply
Where do you live?
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Photo of Your Drivers License
(Required)
Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.
Your photo in active wear or swimsuit
(Required)
Accepted file types: jpg, jpeg, png, pdf, heic, raw, Max. file size: 50 MB.
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HOME
About us
About us
Press
Before & After
Body
CoolSculpting
Sculptra Butt Lift
Sculptra Hip Dips
Liquid Butt Lift
Liquid Breast Lift
Hand Filler
Avéli
Penis Filler
Face
Injectables
Botox
Liquid Facelift
Forehead Filler
Under Eye Filler
Nose Filler
Cheek Filler
Smile Line Filler
Lip Filler
Russian Lip Filler
Jawline Filler
Chin Filler
Kybella
Advanced /Non-Surgical
Liquid Facelift
PDO Thread Lift
Upneeq
Face
Botox
Crow’s Feet
Eyebrow Lift
Masseter
Chin
Lip Flip
Baby Botox
Neck-Tox
Trap-Tox
DAO Botox
TMJ Botox
Hyperhidrosis
Types of Toxin
Botox
Dysport
Fillers
Liquid Facelift
Forehead Filler
Under Eye Filler
Liquid Rhinoplasty
Cheek Filler
Nasolabial Fold Filler
Lip Filler
Russian Lips
Jawline Filler
Chin Filler
Brands
Juvederm
Volume
Ultra
Volbella
Volux
Restylane
Radiesse
RHA Fillers
Sculptra
Non-Surgical
PDO Thread
Endolift
Ellacor
Ultherapy
Upneeq
Lasers
Endolift
CO2 Laser
Pure Plasma Laser
Fraxel
Carbon Laser
Microneedling
RF Microneedling
Secret RF
Morpheus8
Agnes RF
Mechanical
DermaPen
AquaGold
Biostimulators
Exosome
Skin Booster
HydraFacial
Filler Dissolving
Hyaluronidase
Kybella
Body
Injectable BBL
Sculptra BBL
Hip Dip Correction
Brazilian Butt Lift
Liquid Butt Lift
Non-Surgical BBL
Liquid Breast Lift
Aveli Cellulite
Hand Rejuvenation
Penile Augmentation
Girth Enhancement
Penile Filler Cost
Muscle Tone
CoolTone
Emsculpt
Coolsculpting
CoolSculpting for Abdomen
CoolSculpting for Double Chin
CoolSculpting For Bra Fat
CoolSculpting for Thighs
CoolSculpting For Back Fat
QWO Cellulite Treatment
Laser Tattoo Removal
Weight Loss
Semaglutide
Tirzepatide
Ozempic
Wellness
NAD+ Therapy
BHRT
Natural Growth Hormone
IV Therapy
Addyi Low Libido Treatment
Blog
Shop
Consult
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