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Reach your goal weight fast
without restrictive diets and exercise.
Let us calculate your BMI to make sure you are a good candidate for medical weight loss
What is your height and weight?
Feet
Inches
Weight (in lbs)
What is your goal weight?
Are you male or female?
Male
Female
What is your date of birth?
Health Questions 1: Do any of these apply to you?
End-stage kidney disease (on or about to be on dialysis)
End-stage liver disease (cirrhosis)
Current suicidal thoughts and/or prior suicidal attempt
Glaucoma
Cancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years - does not apply to non-melanoma skin cancer that was considered cured via simple excision)
Severe gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)
Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependence
None of these
Health Questions 2: Do any of these apply to you?
Gallbladder disease
Hypertension (high blood pressure)
Seizures
Glaucoma
Sleep apnea
Type 2 diabetes (not on insulin)
Type 2 diabetes (on insulin)
Diabetic retinopathy (diabetic eye disease), damage to the optic nerve from trauma or reduced blood flow, or blindness
Use of the blood thinner warfarin (Coumadin/Jantoven)
History of or current pancreatitis
Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2
Gout
High cholesterol or triglycerides
Depression
Head injury
Tumor/infection in brain/spinal cord
Low sodium
Liver disease, including fatty liver
Kidney disease
None of these
In the past 3 months, have you used any opioid-based medications or substances?
Yes
No
Have you had prior weight loss surgeries?
Yes
No
Do you currently take any medications?
Yes
No
What is your current or average blood pressure range?
<120/80 (Normal)
120-129/<80 (Elevated)
130-139/80-89 (High Stage 1)
≥140/90 (High Stage 2)
What is your current or average heart rate range?
<60 beats per minute (Slow)
60-100 beats per minute (Normal)
101-110 beats per minute (Slightly Fast)
>110 beats per minute (Fast)
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