Last Name
First Name
Phone
Email
Lifestyle and Medication
Lifestyle Commitment
Are you willing to reduce your caloric intake alongside medication?
*
Yes
No
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Are you willing to increase your physical activity alongside medication?
*
Yes
No
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Current Medical Supervision
Are you currently taking any prescription medications for weight loss?
*
Yes
No
Provide GLP medications and dose prescribed
*
e.g., Wegovy 2.4 mg
When was your last in-person medical evaluation?
*
Less than a year ago.
1 to 2 years.
More than 2 years ago.
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Have you had lab tests within the past 6 months that you want to share with your doctor?
*
Yes
No
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Please provide your most recent blood pressure measurement. (e.g., 120/80)
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