Full Name
*
Email
*
Phone
Which state are you currently located in?
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
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
Outside USA
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What is your current height and weight (or most recent BMI, if you know it)?
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Height
Weight
Do you have any of the following diagnoses? (Check all that apply)
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Type 2 diabetes
Prediabetes / insulin resistance
PCOS
Metabolic syndrome
Fatty liver (NAFLD)
Hypertension
Dyslipidemia
Sleep apnea
Hypothyroidism / Hashimoto’s
None of the above
Have you ever been diagnosed with any of the following conditions?
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Pancreatitis
Gallbladder disease or gallstones
Gastroparesis (slow stomach emptying)
Inflammatory bowel disease (Crohn’s/Ulcerative Colitis)
Severe chronic constipation
I’m not sure / I don’t know
None of the above
Personal or family history of medullary thyroid carcinoma (MTC) or MEN2?
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Yes
No
I’m not sure / I don’t know
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Are you currently pregnant, breastfeeding, trying to conceive in the next 6–12 months, or not using reliable contraception if you could become pregnant?
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Yes
No
Not Applicable
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List all current medications and supplements (including any weight-loss medications or GLP-1s you’ve used before).
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(Name + dose if known + how you tolerated them)
In the past 12 months, have you had any of the following “red flag” symptoms?
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Persistent severe abdominal pain
Repeated vomiting
Fainting / blackouts
Chest pain
Uncontrolled depression / suicidal thoughts
Eating disorder diagnosis (current or past)
None of the above
What is your primary goal over the next 12–16 weeks?
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Examples: lose 20+ lbs, reduce A1c, improve energy, reduce cravings/food noise, build muscle, improve labs
Which best describes your weight journey?
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First serious attempt
Multiple attempts with regain
Significant weight loss previously
Post-pregnancy
Peri-menopause/menopause transition
Medication-related gain
How would you describe your eating pattern most days?
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Regular meals
Frequent snacking
Skipping meals
Night eating
Emotional/stress eating
Binge episodes
High alcohol intake
How many days per week can you realistically commit to strength training or structured movement?
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0-1
2
3
4+
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Do you have reliable access to protein-forward foods and basic meal prep capability?
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Yes
Somewhat
Not Currently
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(kitchen access, grocery budget, time)
Do you have a primary care clinician, and are you willing to complete baseline labs (and periodic monitoring) as part of safe GLP-1 care?
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Yes
No
Unsure
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How ready are you to follow through for the next 12 weeks?
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0
1
2
3
4
5
6
7
8
9
10
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On-Scale of 0-10 (10 being the highest)
What would move you 1–2 points higher?
Financial and logistics fit (select what applies):
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I can invest in a premium, provider-led program and ongoing support
I understand GLP-1 medication cost/coverage varies and I’m prepared for out-of-pocket scenarios if needed
I have a stable schedule for appointments/check-ins
I’m not sure yet / I’d like to discuss options
If you selected “I’m not sure” or have any constraints, please share briefly:
