1 of 10

What is your current weight?

What is your height?

Ex: 5'5

2 of 10

Are you currently pregnant or breastfeeding?

Yes

3 of 10

Have you been diagnosed with any of the following medical conditions:

None of the below

Chronic pancreatitis or previous episode of pancreatitis due to GLP-1

History of type 1 diabetes

History of severe GI disease (Ex: Crohn’s disease, or ulcerative colitis)

History of diabetic retinopathy

History of medullary thyroid cancer

Recent bariatric surgery or other GI surgery (within the last 6 months)

History of MEN-2 (multiple endocrine neoplasia syndrome type 2)

History of gallbladder disease (not including gallbladder removal/cholecystectomy)

Liver disease/cirrhosis

Leber Hereditary Optic Neuropathy (LHON)

None of the above

select all that apply

4 of 10

Have you been diagnosed with any of the following medical conditions:

History of kidney failure

History of chronic renal failure

Seen a kidney specialist in the past 12 months

History of solitary kidney, or kidney transplant

None of the above

5 of 10

Do you drink any alcohol?

Less than 2/day or <5 on one occasion

2+ per day or 5+ on one occasion

Almost never or never

6 of 10

Have you been diagnosed with any new medications or had surgery in the last year?

Yes

7 of 10

Are you taking any other weight loss medications currently?

Yes

8 of 10

Have you ever experienced any allergic reaction to semaglutide, tirzepatide, liraglutide, or any GLP-1 medication?

Yes

9 of 10

Have you had any blood work within the last year from your medical provider that you would like to provide?

Yes

10 of 10

Are you taking any other prescription medications that are unrelated to weight loss?

Yes

Are you from Colorado?

Yes

Find Out If You're Eligible!

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