Step 1 of 10 10% Who do I have the pleasure of talking to? First Last What was your gender at birth? Male Female Are you pregnant or breastfeeding? Yes No What is your date of birth? MM slash DD slash YYYY What is your height? What is your current weight? Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries? Yes No Do you have any of these medical conditions? Type 2 diabetes ON INSULIN Type 1 diabetes Diabetic retinopathy End-stage liver disease (cirrhosis) End-stage kidney disease (on or about to be on dialysis) Current or prior eating disorder (anorexia/bulimia) Current suicidal thoughts and/or prior suicidal attempts History an organ transplant on anti-rejection medication Severe gastrointestinal condition (gastroparesis, blockage, inflammatory disease) Personal or family history of thyroid cyst/nodule, thyroid cancer, medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2 History of or current pancreatitis None of the above What is your mobile phone number? Please enter your email
