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Reach your goal weight fast
without restrictive diets and exercise.
Let us calculate your BMI to make sure you are a good candidate for medical weight loss
What is your height and weight?
Feet
Inches
Weight (in lbs)
What is your goal weight?
Are you male or female?
Male
Female
What is your date of birth?
Medical History
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 attempt
Glaucoma
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
Gallbladder disease
Bariatric surgery within the last 6 months
Hypertension (high blood pressure)
Seizures
Sleep apnea
Type 2 diabetes (not on insulin)
Type 2 diabetes (on insulin)
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
Pancreatitis from weight-loss medications
Personal history of medullary thyroid cancer or Multiple Endocrine Neoplasia Type 2 (MEN-2)
Gout
High cholesterol or triglycerides
Depression
Head injury
Tumor/infection in brain/spinal cord
Low sodium
Liver disease, including fatty liver
Kidney disease
None of these
Does anyone in your family have any of the following?
Medullary thyroid cancer
Multiple Endocrine Neoplasia Type 2 (MEN-2)
None of the above
Do you currently take any medications?
Yes
No
Do you have any medication allergies?
Yes
No
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