Full Name
*
Email
*
Date of birth
*
Gender
*
male
female
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Current Weight
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Please list your current weight in pounds
Which Weight Loss Medication are you currently taking?
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Semaglutide
Tirzepatide
Are you satisfied with your progress over the past week?
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Yes
No
Have you experienced a noticeable reduction in your appetite?
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Yes
No
How would you rate your food choices over the past week?
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Excellent
Good
Poor
We've definitely seen better days
Over the last week you have exercised...
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5-7 days
3-5 days
1-3 days
What is exercise???
Have you experienced 1 or more of the following symptoms during the past week?
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Nausea
Vomiting
Diarrhea
Constipation
Heartburn or Acid Reflux
Fatigue
Hiccups
Other not listed
I have not experienced any negative symptoms
Severity
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Mild
Moderate
Severe
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If you selected "Other" on the previous question please explain
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Are you currently also taking Sermorelin, CJC-1295/Ipamorelin, IGF-LR3, or Tesamorelin to prevent muscle loss and accelerate fat loss?
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Yes
No
Are you currently also taking B Vitamin weight loss injections to improve mood and energy levels during your weight loss?
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Yes
No
Are you currently receiving any meal planning, weight loss coaching , or personal training either in person or at home?
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Yes
No
Are you currently taking Akkermansia or ABC (Akkermansia-BPC-Complex) to help with gut health and reduce food cravings?
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Yes
No
Please list any other information you would like to share regarding the past 2 weeks
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Would you like to schedule an appointment with a provider?
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Yes
No
Do you need a medication refill?
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Yes
No
Submit