Quiz

Step 1 of 24

We’ve helped over 40,000+ patients on their weight loss journeys. Let’s answer a few quick questions to kickstart yours and help you lose up to 1 pound daily!

What is your weight loss goal?

Lose 1-20 lbs for good

Lose 21-50 lbs for good

Lose over 50 lbs for good

Maintain my weight and get fit

Haven't decided

What is your current height & weight?

Feet(Required)

Inches(Required)

Weight (in lbs)(Required)

What is your gender?(Required)

Male

Female

What is your date of birth?(Required)

MM slash DD slash YYYY

Our GLP-1 plans are popular because they work!

Here's what you could lose based off a sample of Forney Weight Loss Meds patients

Where are you located?(Required)

State

We can assist with all of these. For the time being, pick the most important to you.

What is the main reason you want to make a change?

I want to increase my life expectancy

I want to improve my appearance

I want to minimize my health risks

I want to boost my mental health

Do any of the following apply to you?

None of the below

Currently or possibly pregnant, or actively trying to become pregnant

Breastfeeding or bottle-feeding with breastmilk

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

End-stage liver disease (cirrhosis)

Current or prior eating disorder (anorexia/bulimia)

Current suicidal thoughts and/or prior suicidal attempt

Cancer

History of organ transplant on anti-rejection medication

Severe gastrointestinal condition

Are you currently taking or have recently (within the last 12 months) taken medication(s) for weight loss?

Yes, I currently take or have recently taken a GLP-1 medication for weight loss

Yes, I currently take or have recently taken another medication for weight loss

Please include name, dose, and frequency of all your medications.

Do you currently take any medications? If so, please include name, dose, and frequency of all your medications.

Yes

Please include name, dose, and frequency of all your medications.

Have you taken any prescription medications to lose weight before?

Yes

Please include date range, name, dose, and frequency.

Are you currently taking, plan to take, or have recently (within the last 3 months) taken opiate pain medications and/or opiate-based street drugs?

Yes

Please include date range, name, dose, and frequency.

Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?

Yes

Please provide details about your bariatric surgery or abdominal/pelvic surgeries.

Have you ever attempted to lose weight in a weight management program, such as through caloric restriction, exercise, or behavior modification?

Yes

Please provide brief details?

Are you willing to

Neither of these

Reduce your caloric intake alongside medication, if clinically appropriate

Increase your physical activity alongside medication, if clinically appropriate

How has your weight changed in the last 12 months?

Lost a significant amount

Lost a little

About the same

Gained a little

Gained a significant amount

Do any of these apply to you?

None of the below

Acid reflux

Depression

High cholesterol or triglycerides

Sleep apnea

Hypertension (high blood pressure)

Gallbladder disease

Alcohol/substance use disorder

Seizures

Glaucoma

Type 2 diabetes (not on insulin)

Type 2 diabetes (on insulin)

Type 1 diabetes

Diabetic retinopathy (diabetic eye disease)

History of or current pancreatitis

Gout

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

Congestive heart failure

QT prolongation or other heart rhythm disorder

Hospitalization within the last 1 year

Human immunodeficiency virus (HIV)

Asthma/reactive airway disease

Urinary stress incontinence

Polycystic ovarian syndrome (PCOS)

Clinically proven low testosterone

Osteoarthritis

Constipation

Hyperemesis gravidarum (nausea/vomiting in pregnancy)

Have you been diagnosed with prediabetes or type 2 diabetes?

Yes

What is your current or average blood pressure range?

I'm not sure

<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 resting heart rate range?

I'm not sure

<60 beats per minute (Slow)

60-100 beats per minute (Normal)

101-110 beats per minute (Slightly Fast)

>110 beats per minute (Fast)

Do you have any medication allergies?

Yes

Allergy details

Are you concerned about any of the following to the level of impacting your ability to take medication regularly?

Injecting yourself under the skin with a needle

Nausea or vomiting as a side effect

Loss of muscle mass as a side effect

None of the above

Do you happen to have any further information which you would like us to know?

Yes

Please let us know details

Name(Required)

First Last

Email(Required)

Phone

Consent(Required)

I agree to receive texts regarding order updates, shipment notifications, messages from my provider, and marketing offers

Quiz

We’ve helped over 40,000+ patients on their weight loss journeys. Let’s answer a few quick questions to kickstart yours and help you lose up to 1 pound daily!

What is your current height & weight?

Our GLP-1 plans are popular because they work!

Here's what you could lose based off a sample of Forney Weight Loss Meds patients

We can assist with all of these. For the time being, pick the most important to you.

Contact Us

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