weight loss questionnaire

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

Name

First Last

Gender

Male

Female

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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

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