GLP-1 Weight Loss Medication Eligibility Questionnaire Form
Answer the following questions to help determine if you may be eligible to discuss GLP-1 weight loss medication with a healthcare provider.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Height (in feet and inches)
*
Current Weight (in pounds)
*
Have you been diagnosed with any of the following conditions?
*
Type 2 Diabetes
Thyroid Disorders
Pancreatitis
Kidney Disease
None of the above
Are you currently pregnant, breastfeeding, or planning to become pregnant?
*
Yes
No
Are you currently taking any prescription medications?
*
Yes
No
Have you previously tried any weight loss methods or medications?
*
Yes
No
What is your primary reason for seeking GLP-1 weight loss medication?
Submit Eligibility Questionnaire
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