BeautyFit Program : Medical Weight Loss Form

What are your weight management goals? *

Losing Weight

Feeling Healthy

Both

Have you used or considered using a GLP-1 medication? *

Please Select

Yes
No
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Is your BMI less than 21?

Please Select

Yes
No
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BMI is calculated by dividing a person's weight in kilograms by the square of their height in meters.

In the past year, have you tried any of the following methods for weight loss: intermittent fasting, calorie reduction, fasting mimicking diet (Prolon®), supplements, keto, high protein, or low carb diets? *

Please Select

YES
NO
MAYBE
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In the past 12 months, have you undergone surgery, received cancer treatment, or been pregnant or breastfeeding?

Please Select

Yes
No
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What are your current health goals, and why are they important to you right now? *

First Name *

Last Name *

Phone Number *

Email *

Your Date Of Birth *

Gender

Height (Feet) *

Height (Inches) *

Weight (In LBS) *

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