On the BMI chart below locate your height and weight range. Please select your weight class *

A) Normal Weight

B) Overweight

C) Obese & Above

Why This Is Important:
BMI is one of the main factors in determining eligibility for GLP-1 medications. A BMI of 30 or 25–29.9 + with health conditions often qualifies.

Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 3 months? *

A) Yes Pregnant or Breastfeeding

B) Might Be Pregnant

C) No on both

Have you ever been diagnosed with (or have a family history of): *

A. Medullary thyroid carcinoma

B. Multiple Endocrine Neoplasia Type 2 (MEN-2)

C. None Of The Above

Why This Is Important:
These are strict FDA-listed contraindications to GLP-1 medications and require medical exclusion.

If you are overweight or obese, from the list below of known weight-related comorbidities answers below which applies to you. *

A) None At All

B) 1 or more that my lab work has shown or my physician has mentioned

C) 1 or more I have been diagnosed and under the care of a physician.

Known Weight-Related Comorbidities:

Type 2 Diabetes

High Blood Pressure

High Cholesterol

Cardiovascular Disease

Sleep Apnea

Osteoarthritis

Fatty Liver Disease

GERD

PCOS

Metabolic Syndrome

Chronic Kidney Disease

Depression or Anxiety

How committed are you to making long-term nutrition and lifestyle changes alongside medication? *

A) Not committed

B) Somewhat committed

C) Fully committed

When you experience setbacks with weight loss, how do you usually respond? *

A) I quit or stop trying

B) I push through sometimes

C) I stay focused and adapt my plan

What best describes your weight loss struggles? *

A) I’ve tried diets but always gain the weight back

B) I exercise but still can’t lose significant weight

C) I feel like my metabolism or body is working against me

Would you like to know the promos, discounts and pricing? *

Yes

Full Name

Phone *

Email *