What’s your primary goal with weight management right now?
Lose fat
Improve energy
Metabolic health
Performance
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Have you tried medical weight loss injections before?
Yes
No
How did you respond to prior treatment?
Great
Some results
Not effective
Side effects
Do you have any history of pancreatitis, gallbladder disease, or thyroid tumors?
Yes
No
Unsure
What kind of support do you prefer?
Medication- focused
Lifestyle coaching
Both
How soon would you like to see progress?
2–4 weeks
1–3 months
Flexible
Are you currently exercising or open to a simple routine?
Yes
No
Any current medications or conditions we should consider?
Yes
No
How committed do you feel to following a structured plan?
5
4
3
2
1
1 is the lowest and 5 is the highest
Would you like a personalized weight loss injection plan with medical oversight to jump‑start results?
Yes
No
City
*
State
*
First Name
Email
*
Phone
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