9 questions: 1 - 2 minutes
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How would you describe your diet in the past month?
Understanding your diet helps us choose the right treatment for you.
Very healthy
Somewhat healthy
Neither healthy or unhealthy
Someone unhealthy
Very unhealth
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Which level of activity best describes your lifestyle?
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0: Not active
10: Very Active
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How long have you had concerns about your weight?
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0: Less than 6 months
10: More than 5 years
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Do any of the following apply to you?
Select all that apply - past or present.
Liver problems
Kidney problems
Diabetes
Diabetic retinopathy
Gallbladder disease
Gastrointestinal problems
High blood pressure
High cholesterol
Anxiety or depression
Pancreatitis
Personal/family history of medullary thyroid cancer
Personal history of multiple Endocrine Neoplasia Type 2
Opioid use or opioid agonist use (eg. oxycodone, methadone, buprenorphine, etc)
Schizophrenia, mania/hypomania or bipolar disorder
Seizures
Abnormal heart rate
Glaucoma
Heart disease
Obstructive sleep apnea
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5
Does your weight negatively affect your physical or mental health?
Yes, a lot
Yes, somewhat
Not much
Not at all
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What diets have you tried?
Select all that apply - past or present.
Atkins
Keto
Jenny Craig
Low calorie
Paleo
Weight watchers
Other
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Are you currently affected by an eating disorder?
No
No, but I have been in the past
Yes
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5
What is your height and weight?
How tall are you?
What is your current weight
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5
What is your height and weight?
How tall are you?
What is your current weight
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5
Finally, add your email & phone, you'll receive a text shortly with next steps
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