8ee7ac27-9dbd-4803-8494-24af27771c15
Please attest to the following confirming that all information you have provided to us is true and complete. If you do not agree, you may not submit this form.
Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.
SINGLESELECT
['I agree and consent']
21
null
34f3e6d8-d586-4e83-9d92-80e379028fe3
Which type of consultation would you prefer?
SINGLESELECT
['Email and Text Message (Fastest Option)', 'Video', 'Phone Call']
20
null
aadfc2fa-9a65-4bb2-8e0f-32ce24ddfac4
Please upload a government issued form of ID (Driver's License, Passport, etc.): Please be sure that your full name and photo are easily visible
FILE
[]
19
null
1e936765-83cf-4dfc-8ed5-e0e9e76ab263
Please list all of your known allergies:Please type N/A if none
TEXT
[]
18
null
8e3522ed-3872-4237-a1de-7fd3430aa664
List any surgeries you have had in the past: If you haven’t had any surgeries, type N/A
TEXT
[]
17
null
ecab9155-40c6-4c2b-8b4b-d63134cd4de0
Please list all medications you are currently taking:
TEXT
[]
16
{"questionIndex": 15, "response": "Yes", "__typename": "QuestionCondition"}
cf5097a6-d901-43bc-ada9-99379f041a09
Are you currently taking any medications? Including Prescription, Over-The-Counter (OTC), and Supplements
SINGLESELECT
['Yes', 'No']
15
null
132ed42c-23cb-4c68-ae74-684dcda375bd
Please check all current or past medical conditions: Select all that apply
MULTISELECT
['Gallbladder removed', 'Fatty Liver (MASLD or MASH)', 'Cirrhosis or end-stage liver disease', 'Chronic Kidney Disease Stage 3 or greater', 'Hypothyroidism, Hyperthyroidism, or Thyroid Issues', 'None of the above']
CHECKBOXES
14
null
e05be731-dbed-4eb2-9ace-cef176d0d5cf
Please check all current or past medical conditions. Select all that apply
MULTISELECT
['Hypertension (high blood pressure)', 'High cholesterol', 'Type 2 diabetes', 'Obstructive sleep apnea', 'Gout', 'Metabolic syndrome', 'Heart disease, stroke, or peripheral vascular disease', 'Heart Failure', 'Atrial fibrillation or flutter', 'Tachycardia or fast heart rate', 'Any ECG abnormality or heart rhythm abnormality', 'None of the above']
CHECKBOXES
13
null
3d04f207-4c8e-49d3-90b6-883a9ea05b0d
Which of the following conditions do you currently have?
MULTISELECT
['Gastroparesis', 'Pancreatic Cancer', 'Pancreatitis', 'Type 1 diabetes or diabetes requiring insulin', 'Hypoglycemia', 'Medullary Thyroid Cancer (MTC) or family history of MTC', 'Bipolar Disorder', 'Schizophrenia', 'Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome', 'Anorexia or Bulimia', 'Current symptomatic gallstones or active gallbladder disease', 'Active Substance Abuse Disorder']
CHECKBOXES
12
{"questionIndex": 11, "response": "Yes", "__typename": "QuestionCondition"}
d57e169a-a3fa-4a25-add8-ea450a915b5e
Do you currently have any of the following medical conditions: Gastroparesis
Pancreatic Cancer
Pancreatitis
Type 1 Diabetes or Diabetes Requiring Insulin
Hypoglycemia
Medullary Thyroid Cancer (MTC) or family history of MTC
Bipolar Disorder
Schizophrenia
Multiple Endocrine Neoplasia syndrome type 2 (MEN-2) or family history of MEN-2
Anorexia or Bulimia
Current Symptomatic Gallstones or Active Gallbladder Disease
Active Substance Abuse Disorder
SINGLESELECT
['Yes', 'No']
CHECKBOXES
11
null
0d7ccc16-665b-4b19-b1f1-f150666121cd
Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months?
BOOLEAN
[]
10
null
291a3666-24b4-4ec3-a9cd-457fc15ef8d7
Please upload a copy of your current prescription: If you do not have a digital copy of your prescription, it is acceptable to upload an image of you medication label.
FILE
[]
9
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
d727b162-c5a9-4752-9a70-a6eeb137ea86
What was the strength of your last dose?Please provide strength of last dose in milligrams(mg) if known
TEXT
[]
8
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
a114a638-3fb7-45d9-98e3-a7edc5619055
What was the approximate date of your last dose?
DATE
[]
DATEPICKER
7
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
6209a7ae-d493-49ac-ba39-ba4b6354bd82
Which GLP-1 medication are you currently taking?
SINGLESELECT
['Compounded Semaglutide Injections', 'Compounded Tirzepatide Injections', 'Branded Semaglutide (Wegovy or Ozempic)', 'Branded Tirzepatide (Zepbound or Mounjaro)', 'Oral Semaglutide', 'Oral Tirzepatide']
6
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
66f93f63-4a05-4269-87af-73ddd93c1ffe
Are you currently taking any GLP-1 medications?
SINGLESELECT
['Yes', 'No']
CHECKBOXES
5
null
b208efd7-2125-4170-8541-4e63597b64b7
What is your age?
TEXT
[]
4
null
e2dbcd8d-8ec1-40d3-8879-999bf848804f
BMI Calculation
WIDGET_BMI
['1']
3
null
4f368600-6897-4859-87be-f78cf69b193f
What weight loss initiatives have you tried in the past?Select all that apply
MULTISELECT
['Exercise', 'Dieting', 'Weight-loss Supplements ', 'Intermittent Fasting', 'None of the Above']
CHECKBOXES
2
null
93680cd5-150f-4d4b-88e2-6a92e4adb0b4
What are your weight loss goals?
SINGLESELECT
['Lose 1-20lbs for good ', 'Lose 21-50lbs for good', 'Lose over 50 for good ', 'Maintain my healthy weight', 'None of the above', 'other']
1
null
8ee7ac27-9dbd-4803-8494-24af27771c15
Please attest to the following confirming that all information you have provided to us is true and complete. If you do not agree, you may not submit this form.
Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.
SINGLESELECT
['I agree and consent']
21
null
34f3e6d8-d586-4e83-9d92-80e379028fe3
Which type of consultation would you prefer?
SINGLESELECT
['Email and Text Message (Fastest Option)', 'Video', 'Phone Call']
20
null
aadfc2fa-9a65-4bb2-8e0f-32ce24ddfac4
Please upload a government issued form of ID (Driver's License, Passport, etc.): Please be sure that your full name and photo are easily visible
FILE
[]
19
null
1e936765-83cf-4dfc-8ed5-e0e9e76ab263
Please list all of your known allergies:Please type N/A if none
TEXT
[]
18
null
8e3522ed-3872-4237-a1de-7fd3430aa664
List any surgeries you have had in the past: If you haven’t had any surgeries, type N/A
TEXT
[]
17
null
ecab9155-40c6-4c2b-8b4b-d63134cd4de0
Please list all medications you are currently taking:
TEXT
[]
16
{"questionIndex": 15, "response": "Yes", "__typename": "QuestionCondition"}
cf5097a6-d901-43bc-ada9-99379f041a09
Are you currently taking any medications? Including Prescription, Over-The-Counter (OTC), and Supplements
SINGLESELECT
['Yes', 'No']
15
null
132ed42c-23cb-4c68-ae74-684dcda375bd
Please check all current or past medical conditions: Select all that apply
MULTISELECT
['Gallbladder removed', 'Fatty Liver (MASLD or MASH)', 'Cirrhosis or end-stage liver disease', 'Chronic Kidney Disease Stage 3 or greater', 'Hypothyroidism, Hyperthyroidism, or Thyroid Issues', 'None of the above']
CHECKBOXES
14
null
e05be731-dbed-4eb2-9ace-cef176d0d5cf
Please check all current or past medical conditions. Select all that apply
MULTISELECT
['Hypertension (high blood pressure)', 'High cholesterol', 'Type 2 diabetes', 'Obstructive sleep apnea', 'Gout', 'Metabolic syndrome', 'Heart disease, stroke, or peripheral vascular disease', 'Heart Failure', 'Atrial fibrillation or flutter', 'Tachycardia or fast heart rate', 'Any ECG abnormality or heart rhythm abnormality', 'None of the above']
CHECKBOXES
13
null
3d04f207-4c8e-49d3-90b6-883a9ea05b0d
Which of the following conditions do you currently have?
MULTISELECT
['Gastroparesis', 'Pancreatic Cancer', 'Pancreatitis', 'Type 1 diabetes or diabetes requiring insulin', 'Hypoglycemia', 'Medullary Thyroid Cancer (MTC) or family history of MTC', 'Bipolar Disorder', 'Schizophrenia', 'Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome', 'Anorexia or Bulimia', 'Current symptomatic gallstones or active gallbladder disease', 'Active Substance Abuse Disorder']
CHECKBOXES
12
{"questionIndex": 11, "response": "Yes", "__typename": "QuestionCondition"}
d57e169a-a3fa-4a25-add8-ea450a915b5e
Do you currently have any of the following medical conditions: Gastroparesis
Pancreatic Cancer
Pancreatitis
Type 1 Diabetes or Diabetes Requiring Insulin
Hypoglycemia
Medullary Thyroid Cancer (MTC) or family history of MTC
Bipolar Disorder
Schizophrenia
Multiple Endocrine Neoplasia syndrome type 2 (MEN-2) or family history of MEN-2
Anorexia or Bulimia
Current Symptomatic Gallstones or Active Gallbladder Disease
Active Substance Abuse Disorder
SINGLESELECT
['Yes', 'No']
CHECKBOXES
11
null
0d7ccc16-665b-4b19-b1f1-f150666121cd
Are you currently pregnant, breastfeeding, or planning to become pregnant within the next 2 months?
BOOLEAN
[]
10
null
291a3666-24b4-4ec3-a9cd-457fc15ef8d7
Please upload a copy of your current prescription: If you do not have a digital copy of your prescription, it is acceptable to upload an image of you medication label.
FILE
[]
9
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
d727b162-c5a9-4752-9a70-a6eeb137ea86
What was the strength of your last dose?Please provide strength of last dose in milligrams(mg) if known
TEXT
[]
8
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
a114a638-3fb7-45d9-98e3-a7edc5619055
What was the approximate date of your last dose?
DATE
[]
DATEPICKER
7
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
6209a7ae-d493-49ac-ba39-ba4b6354bd82
Which GLP-1 medication are you currently taking?
SINGLESELECT
['Compounded Semaglutide Injections', 'Compounded Tirzepatide Injections', 'Branded Semaglutide (Wegovy or Ozempic)', 'Branded Tirzepatide (Zepbound or Mounjaro)', 'Oral Semaglutide', 'Oral Tirzepatide']
6
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
66f93f63-4a05-4269-87af-73ddd93c1ffe
Are you currently taking any GLP-1 medications?
SINGLESELECT
['Yes', 'No']
CHECKBOXES
5
null
b208efd7-2125-4170-8541-4e63597b64b7
What is your age?
TEXT
[]
4
null
e2dbcd8d-8ec1-40d3-8879-999bf848804f
BMI Calculation
WIDGET_BMI
['1']
3
null
4f368600-6897-4859-87be-f78cf69b193f
What weight loss initiatives have you tried in the past?Select all that apply
MULTISELECT
['Exercise', 'Dieting', 'Weight-loss Supplements ', 'Intermittent Fasting', 'None of the Above']
CHECKBOXES
2
null
93680cd5-150f-4d4b-88e2-6a92e4adb0b4
What are your weight loss goals?
SINGLESELECT
['Lose 1-20lbs for good ', 'Lose 21-50lbs for good', 'Lose over 50 for good ', 'Maintain my healthy weight', 'None of the above', 'other']
1
null
7e655f3c-a98b-4aff-bb92-7d4864b1b154
Final Step! – Please confirm that all the information you've provided is true and complete.
Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.
SINGLESELECT
['I agree and consent']
19
null
143deabd-3d55-4382-8613-0f0a51fba345
Which type of consultation do you prefer? (Let us know what works best for you!)
SINGLESELECT
['Email and Text Message (Fastest Option)', 'Video', 'Phone Call']
18
null
36ce7515-aee8-4c2e-8a43-22263012f189
Please upload a valid photo ID (A driver's license or passport will do!)
FILE
[]
17
null
458f24e5-5c1b-4f43-977f-d3e1d3017d16
Do you have any allergies? (If none, just type “N/A.”)
TEXT
[]
16
null
4577818a-70a2-45a1-9452-3573bc3193b7
Have you ever had surgery? (If so, please list them or type “N/A” if none.)
TEXT
[]
15
null
6fa95f6f-5860-4f1d-a834-adbe1a8284cb
Are you currently taking any medications, including prescriptions, over-the-counter meds, or supplements? If yes, please list them here! (The more details, the better!)
TEXT
['Exercise', 'Dieting', 'Weight-loss Supplements ', 'Intermittent Fasting', "Other GLP1's", 'Other']
CHECKBOXES
14
null
3b4fa318-8048-4d97-886d-2849b93c43e3
Do you have any of the following conditions? Did you have any in the past? (Select any that apply.)
MULTISELECT
['Gastroparesis', 'Pancreatitis', 'Type 1 diabetes or diabetes requiring insulin', 'Hypoglycemia', 'Medullary Thyroid Cancer (MTC) or family history of MTC', 'Bipolar Disorder', 'Schizophrenia', 'Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome', 'Anorexia or Bulimia', 'Current symptomatic gallstones or active gallbladder disease', 'Active Substance Abuse Disorder', 'Hypertension (high blood pressure)', 'High cholesterol', 'Type 2 diabetes', 'Obstructive sleep apnea', 'Gout', 'Metabolic syndrome', 'Heart disease, stroke, or peripheral vascular disease', 'Heart Failure', 'Atrial fibrillation or flutter', 'Tachycardia or fast heart rate', 'Any ECG abnormality or heart rhythm abnormality', 'Gallbladder removed', 'Fatty Liver (MASLD or MASH)', 'Cirrhosis or end-stage liver disease', 'Chronic Kidney Disease Stage 3 or greater', 'Hypothyroidism, Hyperthyroidism, or Thyroid Issues', 'None of these']
CHECKBOXES
13
null
10688131-9d65-447d-adb9-793f68dd50c9
Are you pregnant, breastfeeding, or planning to be in the next 2 months? (This helps us provide the safest recommendations!)
BOOLEAN
[]
12
null
fd531536-aedb-4fd8-974c-a6d785ee165d
Is there a particular medication you are interested in discussing with your provider? (Please list below)
SINGLESELECT
['Semaglutide', 'Tirzepatide', 'Whatever my provider recommends']
CHECKBOXES
11
null
33366163-ead0-46c9-8ad6-e695f34d3a46
How are you doing with your medication? (Are you noticing any side effects? Is it working well for you? We'd love to hear your thoughts!)
SINGLESELECT
['I’m NOT losing weight (1-2 pounds/week) and I’m NOT having side effects.', 'I’m NOT losing weight (1-2 pounds/week) and I AM having side effects.', 'I’m losing weight (1-2 pounds/week) but I AM having side effects.', 'I’m losing weight (1-2 pounds/week) and I’m NOT having side effects.']
10
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
d8999d79-5c7a-4346-ac1a-61aec7ee3507
Can you upload a copy of your current prescription? (A photo of the label works too! Please make sure picture includes your name, name of medication, dose, and prescribed date.)
FILE
['Lose 1-20lbs for good ', 'Lose 21-50lbs for good', 'Lose over 50 for good ', 'Maintain my healthy weight', 'None of the above', 'other']
9
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
3c593f4a-ce39-48ca-8fe3-559241b85f9e
What was the strength of your last dose? (In milligrams (mg) if you know it!)
TEXT
['Medullary Thyroid Cancer (MTC) or family history of MTC or Multiple endocrine neoplasia Type 2 or any cancer', 'Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)', 'Serious Allergic reaction to Semaglutide or Tirzepitide or compounded components', 'Active Cancer', 'Active Drug or Alcohol Misuse', 'Eating disorders', 'Bipolar Disorder', 'Schizophrenia', 'Pancreatitis', 'Diabetes mellitus type 1 or Insulin dependent type 2 DM', 'Any liver or Kidney disease', 'Active gallbladder disease', 'Chronic or persistent hypoglycemia with ranges < 60 mg/dl', 'Pregnant or planning to become pregnant in the next 2 months', 'None of the above']
CHECKBOXES
8
{"questionIndex": 5, "response": "", "__typename": "QuestionCondition"}
3bd0ebd5-e89f-4765-b8bf-32ba4bffbedb
When was your last dose? (An estimate is fine!)
DATE
['High Cholesterol', 'Fatty Liver Disease', 'High Blood Pressure', 'Pre Diabetes/ Type 2 Diabetes/ Hbac 1 above 5.7', 'none of the above', 'other']
CHECKBOXES
7
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
b93fe36c-db12-46cd-b0a9-1b121330408c
If yes, which one are you taking? (Please select the name!)
MULTISELECT
['Compounded Semaglutide Injections', 'Compounded Tirzepatide Injections', 'Branded Semaglutide (Wegovy or Ozempic)', 'Branded Tirzepatide (Zepbound or Mounjaro)', 'Oral Semaglutide', 'Oral Tirzepatide']
CHECKBOXES
6
{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}
9e970e20-39fc-4505-b882-96411325b3cb
Are you currently taking any GLP-1 medications? (Medications like Ozempic, Wegovy, etc.)
SINGLESELECT
['Yes', 'No']
5
null
f1cfac3b-c1fd-4fb4-91a9-692626e578d9
How old are you? (Just a number, but it helps us tailor our recommendations!)
TEXT
[]
4
null
05d7fd70-49bb-4caa-9620-f756fb5d95ed
Do you know your BMI (Body Mass Index)? (If not, no worries—we can calculate it!)
WIDGET_BMI
['1']
3
null
6180397f-1e80-41bd-9e28-61f2f03921c8
Have you tried any weight loss programs or strategies in the past? (Check all that apply!)
MULTISELECT
['Exercise', 'Dieting', 'Weight-loss Supplements', 'Intermittent Fasting', 'None of the Above']
CHECKBOXES
2
null
a3028caa-f58a-431e-bc03-ea680152dc07
What are your health and weight loss goals? (Tell us what you're hoping to achieve!)
SINGLESELECT
['Lose 1-20lbs for good', 'Lose 21-50lbs for good', 'Lose over 50lbs for good', 'Maintain my healthy weight', 'None of the above']
1
null
