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Self Assessment

Birthday
Month
Day
Year
Are You 18 Years of Age or Older?

Include dosages if known. This helps us identify any potential drug interactions.

Please share any other relevant medical information, allergies, or questions you may have

Are you currently seeking support for weight management?
Do you have type 2 diabetes?
Are you currently pregnant, trying to become pregnant, or breastfeeding?
Have you ever used a GLP-1 medication (such as semaglutide or tirzepatide) before
Are you ready to start your program in the next 24 hours if you are cleared and eligible?
Do you have any of the following conditions? (Select all that apply)
What GLP are you interested in starting?

Medical Screening

Have you ever been diagnosed with medullary thyroid cancer or MEN2?
Do you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)?
Do you have a history of pancreatitis?
Are you currently taking medications that you believe may conflict with a GLP-1–based program?
Are you currently taking medications that you believe may conflict with a GLP-1–based program?

Committment

Are you looking to start a 1 Month or 3 Month Program?

Acknowledgment

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