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Health Questionnaire for Program Eligibility
Weight loss form
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Full Name
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Email Address
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activity to particularly
Mobile Phone Number
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How old are you?
What is your current weight and height?
Do you have a history of any heart conditions, diabetes, or high blood pressure?
Are you currently taking any medications, especially for diabetes, hypertension, or cholesterol?
Have you tried to lose weight before, and if so, what methods did you use?
How would you describe your daily activity level? Do you smoke or consume alcohol?
What does your typical diet look like? Do you follow any specific dietary patterns or restrictions?
Are you aware of and prepared for the potential side effects of Semaglutide, such as nausea or gastrointestinal discomfort?
Is there a family history of thyroid cancer or other significant health issues?
What are your main motivations for losing weight, and what are your specific goals?
Do you have any known allergies, particularly to medications, or any conditions that might contraindicate the use of Semaglutide?
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