weight loss questionnaire

Skip to primary navigation
Skip to main content
Skip to footer

Boston Medical Group Telemedicine

Call Us!
(800) 337-7555

Book a virtual appointment

Call to Refill Your ICP Now 800 337 7555

Erectile Dysfunction
Premature Ejaculation
Weight Loss
- Weight Loss Injections Guide
Treatment Options
About Us
Blog
Contact

Name

First Last

Gender

Male

Female

This field is hidden when viewing the form

Height

Height

Height

Inches

Weight

Your total weight in Pounds

BMI

BMI is [pounds/(inches)(inches)]x 703 and is pre-calculated for your convenience
A BMI > 30 would qualify for treatment approval

Date of Birth

Year

Month

Day

Phone(Required)

Medical History

Personal or Family History of

Are you currently pregnant, any chance that you may be pregnant, or breastfeeding?

YES

NO

When (or what year) was your most recent gynecological exam?

Year

Month

Day

MEN2

YES

NO

Medullary Thyroid Cancer

YES

NO

Past or Current personal history of

Pancreatitis

YES

NO

Retinopathy

YES

NO

The above 4 conditions represent contra-indications to using GLP-1 and would exclude the approval of this medication

When was your last medical checkup by a doctor?

Note: Your last medical checkup of less than 12 months is necessary for approval of any prescription approval

List all other medical conditions

Surgical History

Family History (of significance)

Medication taken on regular basis (Please take time to list exactly the names and amount taken)

Prior Treatment for Weight loss (please indicate medication taken, dosage and its effectiveness)

Goals of treatment

Name

This field is for validation purposes and should be left unchanged.

Footer

About BMG

The Boston Medical Group Telemedicine is a Men’s Health online network dedicated to research and treatment for Erectile Dysfunction and Premature Ejaculation.
• • • • • • • • • • • • • • • • • • • • • •

Corporate Office

Boston Medical Group Telemedicine
3152 Red Hill Ave. Ste. #280
Costa Mesa, CA 92626

Latest Blog

What Is PT-141 Mechanism, Benefits, and How It Works

What Is PT-141? Mechanism, Benefits, and How It Works

by Boston Medical Group, June 30, 2025

PT-141, commonly known as Bremelanotide, is a … Read More > about What Is PT-141? Mechanism, Benefits, and How It Works

Follow Us

Facebook
Twitter
Instagram
Youtube
Linkedin

Sign up for offers

Email*
This field is hidden when viewing the form
googleclientid
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

© 2025 Boston Medical Group Privacy Policy Terms of Use