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What are your main goals?
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Lose Weight?
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New Yes / No
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Improve general Health?
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New Yes / No
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Look Better?
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New Yes / No
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Improve confidence?
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New Yes / No
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Increase energy?
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New Yes / No
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What have you tried in the past?
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Exercise?
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New Yes / No
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Dieting?
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New Yes / No
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Weight loss supplements?
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New Yes / No
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If yes - what supplements?
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New Short Text Field
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Intermittent fasting?
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New Yes / No
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Medical Weight Loss program?
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New Yes / No
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MEDICAL HISTORY
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Lets calculate your BMI
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Any history of multiple endocrine neoplasia?
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New Yes / No
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Any history of thyroid problems or cancer in your family?
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New Yes / No
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Do you have diabetes?
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New Yes / No
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Do you have high cholesterol?
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New Yes / No
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Do you have high blood pressure?
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New Yes / No
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Do you suffer from depression?
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Do you have any kidney problems?
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New Yes / No
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Your abilities as a patient
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Is your vision adequate to see a small dosing syringe?
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New Yes / No
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Are your comfortable with self injection?
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New Yes / No
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