GLP-1 FDA Approved

Weight Loss

Men's Health

Women's Health

Hair Loss

Skin Care

Supplements

About Us

Contact Support

Follow us

Weight Loss

Men's Health

Women's Health

Hair Loss

Skin Care

Supplements

About Us

Contact Support

Follow us

PATIENT INTAKE · GLP-1 PROGRAM

GLP-1 Weight Loss Intake

Please answer the following questions so our licensed clinical partner can review your eligibility for treatment.

About You

Are you male or female?

Male

Female

Safety Screening

Currently or possibly pregnant, or actively trying to become pregnant

Breastfeeding or bottle-feeding with breastmilk

Have given birth to a child within the last 6 months

None of the above

Contact Information

First Name

Last Name

Email

Phone Number

State you'll be shipped to

Body Measurements & Birth Date

Height (feet)

Height (inches)

Weight (lbs)

Goal weight (lbs)

Date of birth (MM/DD/YYYY)

Health History — Part 1

End-stage kidney disease (on or about to be on dialysis)

End-stage liver disease (cirrhosis)

Current suicidal thoughts and/or prior suicidal attempt

Cancer (active diagnosis, active treatment, or in remission/cancer-free for less than 5 years — excludes non-melanoma skin cancer 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 the above

Health History — Part 2

Untreated hypothyroidism

Gallbladder disease

Hypertension (high blood pressure)

Seizures

Glaucoma

Sleep apnea

Type 2 diabetes (not on insulin)

Type 2 diabetes (on insulin)

Type 1 diabetes

Diabetic retinopathy, optic nerve damage from trauma/reduced blood flow, or blindness

Use of the blood thinner warfarin (Coumadin/Jantoven)

History of or current pancreatitis

Personal/family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or MEN2

Gout

High cholesterol or triglycerides

Depression

Head injury

Tumor/infection in brain/spinal cord

Low sodium

Liver disease, including fatty liver

Kidney disease

Elevated resting heart rate (tachycardia)

Coronary artery disease or heart attack/stroke in last 2 years

Allergic to any medication

Congestive heart failure

QT prolongation or other heart rhythm disorder

Hospitalization within the last 1 year

Human immunodeficiency virus (HIV)

Acid reflux

Asthma/reactive airway disease

Urinary stress incontinence

Polycystic ovarian syndrome (PCOS)

Clinically proven low testosterone

Osteoarthritis

If allergic to a medication, please specify which

Constipation

None of the above

Risk Assessment

Within the last 3 months, have you taken opiate pain medications and/or opiate-based street drugs?

Yes

No

Have you had prior weight loss surgeries?

Yes

No

Do you currently take any prescription medications?

Yes

No

What is your blood pressure range?

Normal (<120/80)

Elevated (120-129/<80)

Hypertension Stage 1 (130-139/80-89)

Hypertension Stage 2 (≥140/90)

What is your average resting heart rate?

Slow (<60 bpm)

Normal (60-100 bpm)

Slightly Fast (101-110 bpm)

Fast (>110 bpm)

Medication History

Have you taken medication for weight loss within the past 4 weeks?

Yes, I've taken GLP-1 medication

Yes, a different weight loss medication

No

GLP-1/weight loss medication name, dose, and frequency (if applicable)

When was your last dose of weight loss medication?

0-5 days ago

6-10 days ago

11-14 days ago

More than 2 but less than 4 weeks ago

More than 4 weeks ago

Starting weight (lbs), if previously on weight loss medication

Do you agree to only obtain weight loss medication through this program moving forward? (It's important not to "stack" weight loss medications.)

Yes

No

Have you ever tried to lose weight in a structured weight management program (e.g. Jenny Craig, Weight Watchers)?

Yes

No

Treatment Preferences

Maintaining muscle mass as I lose weight

Would prefer not to inject

Managing potential side effects such as nausea/vomiting

Assist with aging and longevity (cellular/DNA damage, immune system dysfunction, etc.)

Improving cognitive function and mental clarity

Improving energy levels

Regulating menses and hormonal status

Improving sleep quality

I'm not sure — I'd like to discuss formulation options with a clinician via a live virtual consult

Anything Else?

Anything else you'd like our medical team to know?

Final Consent

I understand my information is never shared, is protected by HIPAA, and I agree to the Terms and Privacy Policy

Reviewed by licensed clinicians within 24–48 hours · Your information is HIPAA-protected and never shared.

prescrYbe

The one ultimate supplement for peak health that replaces your entire shelf

Trusted By

PrescrYbe Health is not a medical provider or pharmacy. Clinical services and prescriptions, when available, will be provided by licensed third-party clinical partners, subject to provider review and approval. Pharmacy fulfillment, where applicable, will be handled by licensed pharmacy partners. This website does not create a doctor-patient relationship.

© Copyright 2026 Prescrybe Health, inc. All rights reserved.

Sections

Policies

Terms & Conditions

Medical Consent