Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Which Weight Loss Medication are you currently taking? *

Semaglutide

Tirzepatide

Retatrutide

Are you satisfied with your progress over the past week? *

Yes

No

Have you experienced a noticeable reduction in your appetite? *

Yes

No

How would you rate your food choices over the past week? *

Excellent

Good

Poor

We've definitely seen better days

Over the last week you have exercised... *

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? *

Please select all that apply

Nausea

Vomiting

Diarrhea

Constipation

Heartburn or Acid Reflux

Fatigue

Hiccups

Other not listed

I have not experienced any negative symptoms

Are you currently also taking Sermorelin, CJC/Ipamorelin, or Tesamorelin to prevent muscle loss and accelerate fat loss? *

Yes

No

Are you currently also taking B Vitamin weight loss injections to improve mood and energy levels during your weight loss? *

Yes

No

Are you currently receiving any meal planning, weight loss coaching , or personal training either in person or at home? *

Yes

No

Are you currently taking Akkermansia or ABC (Akkermansia-BPC-Complex) to help with gut health and reduce food cravings? *

Yes

No

Would you like to schedule an appointment with a provider? *

Yes

No

Do you need a medication refill? *

Yes

No