The first step is to use the BMI calculator to determine if you are a candidate for the program. Candidates must have a minimum of 25 BMI in order to qualify for the program

Clients who do not meet the minimum BMI of 25 cannot continue with the form.

Please contact (475) 206 - 0144 for more infromation

Are you 18 years of age or older?

Yes

No

How would you describe your overall health?

Do you have any medical problems?

What are you allergic to?

What are your biggest health concerns?

What is difficult to do because of your weight?

What are you unable to do, or avoid doing because of your weight?

What are your health goals?

What is your current weight?

What is your current height?

What worked well for you?

What have you tried to lose weight in the past?

What did not?

Have you been diagnosed with an eating disorder or body dysmorphia in the past?

Are you pregnant or breastfeeding?

Yes

No

N/A

Do you have a history of Type 1 DM?

To the best of your knowledge, are you allergic to semaglutide or another GLP-1 receptor agonist?

Do you have a personal or family history of medullary thyroid carcinoma?

Do you have a history of multiple endocrine neoplasia syndrome?

Do you have a history of pancreatitis?

Yes

No

When was your last physical exam?

Do you have a history of end-stage renal disease (on dialysis) or known issues with your kidneys?

Do you drink alcohol?

Yes

No

How many drinks on average per week?

After signing below this form will be sent to our medical director for review. We will reach out to you once approval or denial is received.

Thank you,

Ctls Staff

Signature

Clear

Contact Information:

First Name *

Last Name *

Date of birth *

Email *

Phone *

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