Take a Quiz

Reset^TM Virtual Intake Form

Please provide answers to the best of your knowledge to be evaluated by a physician for prescription weight loss medications.

11%

1. General Information

Do you have a family physician?

Yes

No

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2. Personal Profile

This information will be used for mailing your medication if you qualify.

First Name

Last Name

Phone Number

Address

Date of Birth (DOB)

Email Address*

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3. BMI Calculation

This will be used to determine if you qualify for prescription weight loss medication.

Weight (in lbs or kgs)

Height (in ft or meters)

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4. Weight Loss History

Have you ever tried a weight loss program before?

Yes

No

Do you have a family physician?

Yes

No

Are you currently taking any prescription medication for weight loss?

None at this time

Wegovy/Ozempic/Zepbound/Saxenda/Mounjaro/Trulicity

Semaglutide/Liraglutide/Tirzepatide

Compounded GLP-1 agonists

Other medication for weight loss, not listed above

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5. Medical History

Do you have any of the following conditions?

High Cholesterol

Fatty Liver Disease

High Blood Pressure

Obstructive Sleep Apnea

Pre-Diabetes / Type 2 Diabetes

None of the above

Do you have any of the following conditions?

History of kidney failure

History of Chronic Kidney Disease

History of solitary kidney or kidney transplant

History of Diabetic Retinopathy

History of Medullary Thyroid Cancer

Chronic Pancreatitis or prior episode of pancreatitis

Type 1 Diabetes

History of severe GI Disease (e.g., gastroparesis, Crohn's disease, ulcerative colitis)

Recent bariatric surgery or another GI/abdominal surgery (less than 6 months ago)

History of MEN-2 (Multiple Endocrine Neoplasia Type 2)

History of gallbladder disease (not including gallbladder removal)

Liver Disease or Liver Cirrhosis

None of the above

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6. Family Medical History

Does anyone in your family have a history of:

Medullary Thyroid Cancer

MEN 2 (Multiple Endocrine Neoplasia Syndrome Type 2)

None of the above

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7. Blood Pressure Measurement

Please provide a recent blood pressure measurement within the last 6 months.

Blood Pressure (Systolic/Diastolic):

If you are not sure, please obtain a blood pressure reading at a local pharmacy.

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8. Additional Medical Information

Do you have any other medical conditions that you wish to share with your doctor?

Yes (please describe)

No

Please describe

Are you taking any other medications?

Yes (please list the names and dosages)

No

Please list the names and dosages

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9. Documentation

Please provide an image of your health card:

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