Contains similar active ingredients found in leading brands.

Patient Questionnaire

Patient Information

First Name
Last Name
Date of Birth
Mobile Phone Number

Weight Loss

Do you suffer from type 1 or type 2 diabetes?
What Medications do you take for your diabetes?

Do you have High Blood Pressure/Heart Problems?
Please list all heart issues and medications you take for them.
Are you pregnant or breastfeeding?
Do you have any major medical conditions?
Major Medical Conditions:
Do you take any medications?
Do you have medication allergies (Seasonal, Medication or any other)?
Medication Allergies:
Have you seen the doctor in the last 12 months?
What is the reason you want to lose weight?
What is your weekly alcohol intake?
Do you or have you ever smoked?
Have you ever had an allergic reaction to Mounjaro, Tirzepatide, Semaglutide or any other GLP1?
Have you ever been diagnosed with Multiple Endocrine Neoplasia syndrome?
Do you have a personal or family history of thyroid cancer?
Please specify:
Have you ever been diagnosed with gallbladder, Pancreas, heart or kidney problems?
Please explain:
Have you ever had thoughts of self harm or suicide?
Have you tried other diet methods, Exercise or any other medications?
Please list: