What is your height and how much do you weigh?

[]

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How about your average resting heart rate?

['<60 beats per minute (Slow)', '60-100 beats per minute (Normal)', '101-110 beats per minute (Slightly Fast)', '110 beats per minute (Fast)']

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How motivated are you to reach lbs?

[]

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Do you have any further information which you would like our medical team to know?

['No', 'Yes']

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If clinically appropriate, are you willing to:

['Reduce your caloric intake alongside medication', 'Increase your physical activity alongside medication', 'Both', 'None of the above']

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GLP-1 is available as an injection or a dissolvable tablet. Which sounds best?

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Looking good! Let's match you with the best medication.

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What state will your medication be shipped to?

['Alabama', 'Alaska', 'Arizona', 'Arkansas', 'California', 'Colorado', 'Connecticut', 'Delaware', 'District of Columbia', 'Florida', 'Georgia', 'Hawaii', 'Idaho', 'Illinois', 'Indiana', 'Iowa', 'Kansas', 'Kentucky', 'Louisiana', 'Maine', 'Maryland', 'Massachusetts', 'Michigan', 'Minnesota', 'Mississippi', 'Missouri', 'Montana', 'Nebraska', 'Nevada', 'New Hampshire', 'New Jersey', 'New Mexico', 'New York', 'North Carolina', 'North Dakota', 'Ohio', 'Oklahoma', 'Oregon', 'Pennsylvania', 'Rhode Island', 'South Carolina', 'South Dakota', 'Tennessee', 'Texas', 'Utah', 'Vermont', 'Virginia', 'Washington', 'West Virginia', 'Wisconsin', 'Wyoming']

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Please add some details about the current medicine you take.

[]

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Do you currently take any medications?

['No', 'Yes']

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I understand that my information is never shared, is protected by HIPAA and agree to the terms and privacy policies and to be contacted as necessary by Josie and its medical partners and can opt-out at anytime.

[]

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What is your average blood pressure range?

['<120/80 (Normal)', '120-129/<80 (Elevated)', '130-139/80-89 (High Stage 1)', '≥140/90 (High Stage 2)']

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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

[]

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Has your weight changed in the last year?

['Lost a significant amount', 'Lost a little', 'About the same', 'Gained a little', 'Gained a significant amount']

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Please provide brief details.

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How about weight loss programs?Have you ever tried to lose weight in a weight management program (Jenny Craig, Weight Watchers, etc)?

['No', 'Yes']

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Have you had prior weight loss surgeries?

['No', 'Yes']

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

['No', 'Yes']

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Have you taken medication for weight loss within the past 4 weeks?

["Yes, I've taken GLP-1 medication", "Yes, I've taken a different medication for weight loss", 'No']

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Please specify which apply to you (1)

['Gallbladder disease', 'Hypertension (high blood pressure)', 'Seizures', 'Glaucoma', 'Sleep apnea', 'Type 2 diabetes (not on insulin)', 'Type 2 diabetes (on insulin)', 'Type 1 diabetes', 'Diabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindness', 'Use of the blood thinner warfarin (Coumadin/Jantoven)', 'History of or current pancreatitis', 'Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2', 'Gout', 'High cholesterol or triglycerides', 'Depression', 'Head injury', 'Tumor/infection in brain/spinal cord', 'Low sodium', 'Liver disease, including fatty liver', 'Kidney disease', 'Elevated resting heart rate (tachycardia)', 'Coronary artery disease or heart attack/stroke in last 2 years', 'Allergic to any medication', 'Congestive heart failure', 'QT prolongation or other heart rhythm disorder', 'Hospitalization within the last 1 year', 'Human immunodeficiency virus (HIV)', 'Acid reflux', 'Asthma/reactive airway disease', 'Urinary stress incontinence', 'Polycystic ovarian syndrome (PCOS)', 'Clinically proven low testosterone', 'Osteoarthritis', 'Constipation']

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Do any of these apply to you? Gallbladder diseaseHypertension (high blood pressure)SeizuresGlaucomaSleep apneaType 2 diabetes (not on insulin)Type 2 diabetes (on insulin)Type 1 diabetesDiabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindnessUse of the blood thinner warfarin (Coumadin/Jantoven)History of or current pancreatitisPersonal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2GoutHigh cholesterol or triglyceridesDepressionHead injuryTumor/infection in brain/spinal cordLow sodiumLiver disease, including fatty liverKidney diseaseElevated resting heart rate (tachycardia)Coronary artery disease or heart attack/stroke in last 2 yearsAllergic to any medicationCongestive heart failureQT prolongation or other heart rhythm disorderHospitalization within the last 1 yearHuman immunodeficiency virus (HIV)Acid refluxAsthma/reactive airway diseaseUrinary stress incontinencePolycystic ovarian syndrome (PCOS)Clinically proven low testosteroneOsteoarthritisConstipation

['None of these apply to me', 'Yes - one or more apply to me']

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Do any of these apply to you?End-stage kidney disease (on or about to be on dialysis) End-stage liver disease (cirrhosis)Current suicidal thoughts and/or prior suicidal attemptCancer (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)History of organ transplant on anti-rejection medicationSevere gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence

['None of these', 'Yes, one or more of the above']

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How many hours of sleep do you usually get each night?

['More than 9 hours', '8-9 hours', '6-7 hours', 'Less than 5 hours']

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How is your sleep, overall?

[]

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How is that pace for you?

[]

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Improving your life requires motivation.

['I want to live longer', 'I want to feel and look better', 'I want to reduce current health issues', 'All of these']

null

Do you experience any of the following?

[]

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Which of these is your priority?

['Lose weight', 'Gain muscle', 'Maintain my current body']

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Safety, first.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']

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What is your goal weight?Please enter your desired weight in pounds (lbs).

[]

null

What is your height and how much do you weigh?

[]

null

How about your average resting heart rate?

['<60 beats per minute (Slow)', '60-100 beats per minute (Normal)', '101-110 beats per minute (Slightly Fast)', '110 beats per minute (Fast)']

null

How motivated are you to reach lbs?

[]

null

Do you have any further information which you would like our medical team to know?

['No', 'Yes']

null

If clinically appropriate, are you willing to:

['Reduce your caloric intake alongside medication', 'Increase your physical activity alongside medication', 'Both', 'None of the above']

null

Looking good! Let's match you with the best medication.

[]

null

What state will your medication be shipped to?

['Alabama', 'Alaska', 'Arizona', 'Arkansas', 'California', 'Colorado', 'Connecticut', 'Delaware', 'District of Columbia', 'Florida', 'Georgia', 'Hawaii', 'Idaho', 'Illinois', 'Indiana', 'Iowa', 'Kansas', 'Kentucky', 'Louisiana', 'Maine', 'Maryland', 'Massachusetts', 'Michigan', 'Minnesota', 'Mississippi', 'Missouri', 'Montana', 'Nebraska', 'Nevada', 'New Hampshire', 'New Jersey', 'New Mexico', 'New York', 'North Carolina', 'North Dakota', 'Ohio', 'Oklahoma', 'Oregon', 'Pennsylvania', 'Rhode Island', 'South Carolina', 'South Dakota', 'Tennessee', 'Texas', 'Utah', 'Vermont', 'Virginia', 'Washington', 'West Virginia', 'Wisconsin', 'Wyoming']

null

Please add some details about the current medicine you take.

[]

null

Do you currently take any medications?

['No', 'Yes']

null

I understand that my information is never shared, is protected by HIPAA and agree to the terms and privacy policies and to be contacted as necessary by Josie and its medical partners and can opt-out at anytime.

[]

null

What is your average blood pressure range?

['<120/80 (Normal)', '120-129/<80 (Elevated)', '130-139/80-89 (High Stage 1)', '≥140/90 (High Stage 2)']

null

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

[]

null

Has your weight changed in the last year?

['Lost a significant amount', 'Lost a little', 'About the same', 'Gained a little', 'Gained a significant amount']

null

How about weight loss programs?Have you ever tried to lose weight in a weight management program (Jenny Craig, Weight Watchers, etc)?

['No', 'Yes']

null

Have you had prior weight loss surgeries?

['No', 'Yes']

null

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

['No', 'Yes']

null

Do you agree to only obtain weight loss medication through this program moving forward? *It's important not to "stack" weight loss medications

['Yes', 'No']

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What was your starting weight in pounds?

[]

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When was your last dose of medication?

['0-5 days', '6-10 days', '11-14 days', 'More than 2 weeks ago but within the last 4 weeks', 'More than 4 weeks ago']

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Please list the name, dose, and frequency of your GLP-1 medication.

[]

null

Have you taken medication for weight loss within the past 4 weeks?

["Yes, I've taken GLP-1 medication", "Yes, I've taken a different medication for weight loss", 'No']

null

Please specify which apply to you (1)

['Gallbladder disease', 'Hypertension (high blood pressure)', 'Seizures', 'Glaucoma', 'Sleep apnea', 'Type 2 diabetes (not on insulin)', 'Type 2 diabetes (on insulin)', 'Type 1 diabetes', 'Diabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindness', 'Use of the blood thinner warfarin (Coumadin/Jantoven)', 'History of or current pancreatitis', 'Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2', 'Gout', 'High cholesterol or triglycerides', 'Depression', 'Head injury', 'Tumor/infection in brain/spinal cord', 'Low sodium', 'Liver disease, including fatty liver', 'Kidney disease', 'Elevated resting heart rate (tachycardia)', 'Coronary artery disease or heart attack/stroke in last 2 years', 'Allergic to any medication', 'Congestive heart failure', 'QT prolongation or other heart rhythm disorder', 'Hospitalization within the last 1 year', 'Human immunodeficiency virus (HIV)', 'Acid reflux', 'Asthma/reactive airway disease', 'Urinary stress incontinence', 'Polycystic ovarian syndrome (PCOS)', 'Clinically proven low testosterone', 'Osteoarthritis', 'Constipation']

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Do any of these apply to you? Gallbladder diseaseHypertension (high blood pressure)SeizuresGlaucomaSleep apneaType 2 diabetes (not on insulin)Type 2 diabetes (on insulin)Type 1 diabetesDiabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindnessUse of the blood thinner warfarin (Coumadin/Jantoven)History of or current pancreatitisPersonal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2GoutHigh cholesterol or triglyceridesDepressionHead injuryTumor/infection in brain/spinal cordLow sodiumLiver disease, including fatty liverKidney diseaseElevated resting heart rate (tachycardia)Coronary artery disease or heart attack/stroke in last 2 yearsAllergic to any medicationCongestive heart failureQT prolongation or other heart rhythm disorderHospitalization within the last 1 yearHuman immunodeficiency virus (HIV)Acid refluxAsthma/reactive airway diseaseUrinary stress incontinencePolycystic ovarian syndrome (PCOS)Clinically proven low testosteroneOsteoarthritisConstipation

['None of these apply to me', 'Yes - one or more apply to me']

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Do any of these apply to you?End-stage kidney disease (on or about to be on dialysis) End-stage liver disease (cirrhosis)Current suicidal thoughts and/or prior suicidal attemptCancer (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)History of organ transplant on anti-rejection medicationSevere gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence

['None of these', 'Yes, one or more of the above']

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How many hours of sleep do you usually get each night?

['More than 9 hours', '8-9 hours', '6-7 hours', 'Less than 5 hours']

null

How is your sleep, overall?

[]

null

How is that pace for you?

[]

null

Improving your life requires motivation.

['I want to live longer', 'I want to feel and look better', 'I want to reduce current health issues', 'All of these']

null

Do you experience any of the following?

[]

null

Which of these is your priority?

['Lose weight', 'Gain muscle', 'Maintain my current body']

null

Safety, first.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']

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What is your goal weight?Please enter your desired weight in pounds (lbs).

[]

null

['I agree and consent']

null

['Email and Text Message (Fastest Option)', 'Video', 'Phone Call']

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[]

null

[]

null

[]

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[]

{"questionIndex": 15, "response": "Yes", "__typename": "QuestionCondition"}

['Yes', 'No']

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['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']

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['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']

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['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']

{"questionIndex": 11, "response": "Yes", "__typename": "QuestionCondition"}

['Yes', 'No']

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[]

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[]

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

[]

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

[]

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

['Compounded Semaglutide Injections', 'Compounded Tirzepatide Injections', 'Branded Semaglutide (Wegovy or Ozempic)', 'Branded Tirzepatide (Zepbound or Mounjaro)', 'Oral Semaglutide', 'Oral Tirzepatide']

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

['Yes', 'No']

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[]

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['1']

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['Exercise', 'Dieting', 'Weight-loss Supplements ', 'Intermittent Fasting', 'None of the Above']

null

['Lose 1-20lbs for good ', 'Lose 21-50lbs for good', 'Lose over 50 for good ', 'Maintain my healthy weight', 'None of the above', 'other']

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['I agree and consent']

null

['Email and Text Message (Fastest Option)', 'Video', 'Phone Call']

null

[]

null

[]

null

[]

null

['Exercise', 'Dieting', 'Weight-loss Supplements ', 'Intermittent Fasting', "Other GLP1's", 'Other']

null

['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']

null

[]

null

['Compounded Semaglutide Injections', 'Compounded Tirzepatide Injections', 'Oral Semaglutide Tablets', 'Oral Tirzepatide Tablets', 'Ozempic', 'Mounjaro', 'Wegovy', 'Rybelsus']

null

['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.']

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

['Lose 1-20lbs for good ', 'Lose 21-50lbs for good', 'Lose over 50 for good ', 'Maintain my healthy weight', 'None of the above', 'other']

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

['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']

{"questionIndex": 5, "response": "", "__typename": "QuestionCondition"}

['High Cholesterol', 'Fatty Liver Disease', 'High Blood Pressure', 'Pre Diabetes/ Type 2 Diabetes/ Hbac 1 above 5.7', 'none of the above', 'other']

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

['Compounded Semaglutide Injections', 'Compounded Tirzepatide Injections', 'Branded Semaglutide (Wegovy or Ozempic)', 'Branded Tirzepatide (Zepbound or Mounjaro)', 'Oral Semaglutide', 'Oral Tirzepatide']

{"questionIndex": 5, "response": "Yes", "__typename": "QuestionCondition"}

['Yes', 'No']

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[]

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['1']

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