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You're just a few questions away from getting the right treatment for weight management!
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Please enter your first name:
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Please enter your last name:
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Please enter your email:
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What was your sex assigned at birth?
Male
Female
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How old are you?
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What is your current height? (in cm)
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What is your current weight? (in kg)
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If you're female, are you currently pregnant, breastfeeding, or planning for pregnancy within the next 2 months?
Select 'None' if you're not female.
Yes, I am pregnant
Yes, I am breastfeeding
Yes, I plan to be pregnant soon
None of the above apply to me
Please select at least one option.
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What is your primary weight loss goal?
Lose 1-7 kg
Lose 8-23 kg
Lose 24 kg or more
I'm not sure of a number, I just want to improve my health
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What would reaching your goal mean for you?
Having more energy
Feeling more confident
Improving my overall health
Feeling better in my clothes and my body
Please select at least one option.
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Do you have a personal or family history of the following specific conditions?
Personal or family history of thyroid cancer
Personal or family history of Multiple Endocrine Neoplasia (MEN-2) syndrome
Pancreatic cancer or pancreatitis
Type 1 Diabetes or history of hypoglycemia
None of the above
Please select at least one option.
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Have you been diagnosed with any of the following medical conditions?
Anorexia or Bulimia
Chronic Kidney Disease (Stage 3 or greater)
Gallbladder disease, gallstones, or past gallbladder removal
Heart disease or other heart conditions
High cholesterol or triglycerides
Hypertension (high blood pressure)
Thyroid issues (Hypo/Hyperthyroidism)
Liver disease (e.g., NAFLD)
Sleep apnea
PCOS with insulin resistance
Type 2 Diabetes or Prediabetes
None of the above
Please select at least one option.
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Is this your first time taking a GLP-1 medication? (e.g., Ozempic, Mounjaro, Wegovy)
Yes
No
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Do you take any of the following medications for diabetes?
Insulin
Glipizide (Glucotrol)
Glimepiride (Amaryl)
Glibenclamide (Glyburide)
Sitagliptin, Saxagliptin, or Linagliptin
None of the above
Please select at least one option.
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Are you allergic to any medications? Please list them below.
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How would you describe your current daily stress level?
Low / I rarely feel stressed
Medium / I feel stressed a few times a week
High / I feel stressed most of the time
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On average, how many hours of sleep do you get per night?
Less than 7 hours
7-9 hours
More than 9 hours
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Do you currently smoke?
Yes
No
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Is there anything else about your medical history, including past surgeries, that you would like to share with the doctor?
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