Check Eligibility to start GLP-1 medicine -

Patient Information

Patient Name

First

Last

Date of Birth

Biological Sex

Phone Number

to Us? Multiple

Email Address

Best Way to Reach You

New or Returning Patient?

How Did You Hear About Us?

Weight & Measurements

Used to determine whether you meet weight criteria for GLP-1 therapy.

Height

Current Weight (lbs)

Goal Weight (lbs)

Known BMI (if you know it)

Leave blank if unknown; the team will calculate it.

Highest Adult Weight (lbs)

Weight-Related Conditions

GLP-1 therapy is typically considered at BMI 30 or higher, or 27 or higher with a weight-related condition. Check any that apply.

Weight-Related Conditions (click all that apply to you)

Safety Screening – Important

These questions identify conditions where GLP-1 medications may not be safe. Please answer honestly – your provider will review each one.

Personal or Family History of Medullary Thyroid Cancer

GLP-1 medications carry a boxed warning and are contraindicated with a personal or family history of medullary thyroid carcinoma.

Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)

A contraindication to GLP-1 therapy.

History of Pancreatitis

History of Gallbladder Disease or Gallstones

Type 1 Diabetes or History of Diabetic Ketoacidosis

Severe Digestive Disorder (e.g., gastroparesis, severe IBD)

History of an Eating Disorder

Pregnancy Status

GLP-1 medications are not used during pregnancy or breastfeeding.

Prior Allergic Reaction to a GLP-1 Medication

Medical History & Medications

Other Current Medical Conditions

Anything not already listed above that your provider should know.

All Current Prescription Medications With Dosages

Include insulin or diabetes medications specifically. Write None if applicable.

Current Supplements

Drug Allergies and Adverse Reactions

Weight Loss & GLP-1 History

Have You Used a GLP-1 Medication Before?

Details of Prior or Current GLP-1 Use

Which medication, dose, how long, and how you tolerated it.

What else Have You Tried for Weight Loss?

Your Goals

Main Goals

Any other goals not listed above?

Consent and Acknowledgment

Please read and confirm each statement before submitting.

Screening Only

Screening Only

Accurate Disclosure

Accurate Disclosure

Off-Label / Compounded

Off-Label / Compounded

Results Not Guaranteed

Results Not Guaranteed

Self-Pay

Self-Pay

Not Emergency Care

Not Emergency Care

Contact Consent

Contact Consent

Electronic Signature (type your full legal name)

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