weight loss questionnaire

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Erectile Dysfunction
Premature Ejaculation
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- Weight Loss Injections Guide
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Name

First Last

Gender

Male

Female

Hidden

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

Phone(Required)

Medical History

Personal or Family History of

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

YES

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

MEN2

YES

Medullary Thyroid Cancer

YES

Past or Current personal history of

Pancreatitis

YES

Retinopathy

YES

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

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

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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.
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Corporate Office

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

Latest Blog

What to Eat (and Avoid) While Taking GLP-1 Medications

by Boston Medical Group, January 22, 2025

GLP-1 medications have revolutionized diabetes … Read More > about What to Eat (and Avoid) While Taking GLP-1 Medications

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