What is your primary goal?

Lose weight

Manage my weight

Improve my overall health

Do any of these apply to you?

Female

Male

Do any of these apply to you?

Currently or possibly pregnant, or actively trying to become pregnant

Breastfeeding or bottle-feeding with breastmilk

Have given birth to a child within the last 6 months

None of the above

Do any of these apply to you?
For your safety, this answer may disqualify you from a prescription

End-stage kidney disease (on or about to be on dialysis)

End-stage liver disease (cirrhosis)

Current suicidal thoughts and/or prior suicidal attempt

Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years — does not apply to non-melanoma skin cancer that was considered cured via simple excision)

Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)

Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence

None of the above

Do you currently take any prescription medications?

Yes

Please list your current prescription medications

Include medication name, dosage, and how often you take it

Do you have any known drug allergies?

Yes

Please list your known drug allergies

Include the medication name and your reaction to it

Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?

Yes

Have you had prior weight loss surgery?

Yes

Please describe your prior weight loss surgery

Include the type of surgery, approximate date, and any complications

Have you tried weight loss programs before?

Yes, diet and exercise

Yes, prescription medication

Yes, multiple approaches

No, this is my first time

Have you used GLP-1 medications before?

Such as Ozempic, Wegovy, Mounjaro, Zepbound, or compounded semaglutide/tirzepatide

Yes

Please list past or current GLP-1 Medication and Dose.

Glp-1 Medication name & Dosing

What state do you live in?

Almost done! Tell us about yourself.

We'll use this to create your account and have a physician review your assessment.

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