Are you eligible for GLP-1 Medication This is a form where you can know if you’re elegible for our product: GLP-1 Medication. Step 1 of 14 7% This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.StartWhat are your goals with WLL program?(Required) Lose weight Improve my general physical health Improve another health condition Increase confidence about my appareance Increase energy for activities I enjoy I have another goal not listed above Select AllAre you in any of the following states?(Required)ALABAMA – ARKANSAS – CALIFORNIA – HAWAII – KANSAS – MICHIGAN – MINNESOTA – MISSISSIPPI Yes No At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours. Let's start with the basics. This information helps your healthcare provider determine if you are eligible for the treatmentSex assigned at birth(Required) Male Female Date of birth(Required) MM slash DD slash YYYY Let's start with where you are nowYour height(Required)FeetInches(Required)InchesYour current weight(Required)PoundsUnfortunately you DO NOT qualify for our GLP-1 program. However, you are a candidate for our fat burners. Would you like to get started with our WLL LOOSE Fat burner pills?(Required) Yes No Unfortunately you do not qualify for our GLP-1 program. However, you are a candidate for our fat burners. Would you like to get started with our WLL LOOSE Fat burner pills?(Required) Yes No Do you have any of these conditions?(Required)Atrial fibrillation or flutter – Tachycardia, episodes of rapid heart rate – Heart disease, stroke or peripheral vascular disease – Prolonged QT interval – Other heart rhythm problems or abnormal ECG – Hypertension, high blood pressure – Hyperlipidemia, high cholesterol – Hypertriglyceridemia, high triglycerides Yes No Thank you for your interest in our program. Are you interested in learning more about our WLL community to learn more about our other Weightloss resources?(Required) Yes No We are going to contact you via email. Stay tunned.We are going to contact you via email. Stay tunned.Thank you for your interest in our program. WLL does not accept public or private insurance, but you can easily cover your order using credit card or PayPal.(Required) Yes, I acknowledge No, I do not acknowledge WLL doesn't accept public or private insurance, but you can easily cover your order using credit card or PayPal.(Required) Yes, I acknowledge No, I do not acknowledge Thank you for your interest in our program.Have you seen your primary care provider in the last 12 months? We want to ensure that there is a provider overseeing your general care options.(Required) Yes No [Ignore if you answered 'Yes' before] We're excited to get you started! Make sure to also see a primary care providerWLL is here to help you meet your goal to lose weight, but we’re not a replacement for a primary care provider. Overweight and obesity are linked to other conditions for where you should get screening and treatment even if you start GLP-1 medication. In rare cases, those conditions can increase your amount of side effects on a GLP-1. In addition to weight management treatment with Ro, it’s important to stablish a relationship with a primary care provider that has a complete picture of your overall health.Do you have any of these conditions ? Select all that apply.(Required) Atrial fibrillation or flutter Tachycardia, episodes of rapid heart rate Heart disease, stroke or peripheral vascular disease Prolonged QT interval Other heart rhythm problems or abnormal ECG Hypertension, high blood pressure Hyperlipidemia, high cholesterol Hypertriglyceridemia, high triglycerides No, I have not been diagnosed with any of these heart conditions Is it medically controlled?(Required) Yes No At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours.Please enter medication and dosage amount.(Required)Do you have, or have you been diagnosed with any of the following hormonal, chemotherapy, or intestinal conditions? Select all that apply.(Required) Multiple endocrine neoplasia syndrome, type 2 Personal history of thyroid cancer Family history of thyroid cancer Chronic kidney disease Diabetes requiring insulin Prediabetes or insulin resistance Fatty liver disease (NAFLD or NASH) Kidney stones Liver cirrhosis or end-stage liver disease Hypothyroidism, low thyroid function Hyperthyroidism, high thyroid function Graves’ disease Thyroid problems Syndrome of inappropriate antidiuretic hormone secretion (SIADH) No, I have not been diagnosed with any of these conditions At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours. Do you have, or have you been diagnosed with Type 2 diabetes?(Required) Yes No No, but I have a parent or grandparent with Type 2 diabetes What was your hemoglobin A1C range in the past months?(Required) Normal – Less than 5.7 Prediabetes – 5.7 to 6.4 Diabetes – 6.5 to 7.9 Uncontrolled diabetes – 8.0 or greater I don’t know Are you insulin dependent?(Required) Yes No At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours. Do you have, or have been diagnosed with diabetic retinopathy?(Required) Yes No I don’t know At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours. [Ignore if you answered 'No' before] As you start WLL Program, check in with your primary care provider about screening for diabetic retinopathy.Patients with overweight and obesity are at risk for having diabetes and its complications. Changes in the eye related to diabetes, specifically “diabetic retinopathy”, can worse in patients using a GLP-1. We recommend that all WLL patients consult with their primary care provider about screening for diabetes and its complications.Do you have or have a history of any of the following intestinal conditions or procedures? Select all that apply.(Required) Bariatric surgery Pancreatitis History of delayed gastric emptying or gastroparesis Gallstones or other gallbladder disease GERD or acid reflux No, I do not have a history of any of these conditions or procedures At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours. Do you have or have you been diagnosed with any of the following additional conditions? Select all that apply.(Required) Chronic fungal infections or candidiasis Eating disorder Gout History of suicide attempt or suicidal ideation Lymphedema or chronic lower extremity swelling where other causes have been ruled out Metabolic syndrome Obstructive sleep apnea Osteoarthritis Tinea infections No, I have not been diagnosed with any of these conditions At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours. Search for and type all allergies you have. Include allergies to prescription or over-the-counter medications, herbs, vitamins, supplements, foods, dyes, or anything else. Our clinicians use this information to determine a safe and effective treatment. If you do not have, please type 'I have no allergies'(Required)Do you have an allergy to GLP-1 agonist medications? Examples include Tricipatide, Subcutaneous Mounjaro, Liraglutide, Saxenda, Victoza, Semaglutide, Wegovy, Ozempic and Dulaglutide (Trulicity)(Required) Yes (any) No Unfortunately you DON'T qualify for our GLP-1 program. However, you are a candidate for our fat burners. Would you like to get started with our WLL LOOSE Fat burner pills?(Required) Yes No Do you have any of these conditions ?(Required)Atrial fibrillation or flutter – Tachycardia, episodes of rapid heart rate – Heart disease, stroke or peripheral vascular disease – Prolonged QT interval – Other heart rhythm problems or abnormal ECG – Hypertension, high blood pressure – Hyperlipidemia, high cholesterol – Hypertriglyceridemia, high triglycerides Yes No Thank you for your interest in our program, are you interested in learning more about our WLL community to learn more about our other Weightloss resources?(Required) Yes No We are going to contact you via email. Stay tunned.We are going to contact you via email. Stay tunned.Thank you for your interest in our program. Are you currently taking any of the following medications? Select all that apply.(Required) Liraglutide, Dulaglutide Sulfonylureas such as, but not limited to, Glipizide, Glimepiride, or Amaryl Insulin Warfarin, also known as Coumadin, a blood thinner that usually requires lab monitoring Meglitinides such as, but not limited to, Repaglinide or Nateglinide Diuretics such as, but not limited to, Furosemide, Lasix, Bumetanide, Bumex, or Hydrochlorothiazide (HCTZ) Selective Serotonin Reuptake Inhibitors (SSRIs) such as, but not limited to, Citalopram (Celexa), Fluoxetine (Prozac), or Escitalopram (Lexapro) Monoamine Oxidase Inhibitors (MAOIs) such as, but not limited to, Phenelzine (Nardil) or Selegiline (Emsam) Exenatide None of the above At this moment one of our specialists will review your file and will be in contact with you in the next 48 hours. Have you ever taken Semaglutide, Terzpetide, Ratutatide or any other GLP-1 Medication / Compound product in the past?(Required) Yes No Has it been in the last 6 months?(Required) Yes No Search for and type any medications, vitamins, dietary supplements, and topical creams you are currently taking or using. Include prescriptions and over-the-counter medications, herbs, minerals, inhalers, injections, and implanted medications or patches. Do not include medications that WLL is prescribing. If you are not using any medications please type 'No, I am not using any medications'(Required) Are you looking for a new provider?(Required) Yes No How would you describe yourself? Select all that apply. Knowing your race and ethnicity will help us work towards improving equitable access to quality healthcare for everyone on our platform. However, you do not need to provide this information, and it will not affect your treatment if you choose not to.(Required) White Hispanic or Latino Black or African American Native American or American Indian Asian and Pacific Islander Other Prefer not to answer Is there anything else you want your healthcare provider to know about your health? Please include any additional details about the conditions you have already reported.(Required) Yes No Type(Required)
