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Name

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What is your weight loss goal?

Lose 1-20lbs Lose 21-50lbs Lose over 50lbs I’m not sure

How old are you?

Under 18 18-29 30-39 40-49 50-63 64+

Have you been diagnosed with diabetes?

Yes Type 1 Yes Type 2 No

For us To Give You The Most Accurate Results Please Tell Us your Current Height And Weight.

With GLP-1 Medication You Can Lose Up To 20% of Your Current Bodyweight In 6-12 Months.

Height

Weight

Do you have any of the following medical conditions?

Heart Disease High Blood Pressure High Cholesterol Type 2 Diabetes Sleep Apnea High Blood Sugar Fatty Liver I do not have any of these conditions

What state do you live in?

Please enter your date of birth

Please select your sex at birth

Male Female

Any history of Pancreatitis?

Yes No

Do you have a personal or family History with thyroid cancer?

Yes No

Have you had any of the following conditions?

IBS Crohns Disease Ulcerative Colitis Gastroparesis Suicidal Ideation Gall Stones None of the above