Your Glow-Up Starts here with GLP-1 treatments by Options Medical Weight Loss

What is your height and weight?*

Feet

Inches

Weight (in lbs)

What is your goal weight?

Are you male of female?

Female

Male

What is your date of birth?*

Month

Day

Year

Health Question 1: Do any of these apply to you?*

End-stage liver disease (cirrhosis)End-stage kidney disease (on or about to be on dialysis)Current suicidal thoughts and/or prior suicidal attemptCancer (active diagnosis, active treatment, or in remission or cancer-free for less than 5 continuous years - does not apply to non-melanoma skin cancer that was considered cured via simple excision)History of organ transplant on anti-rejection medicationSevere gastrointestinal condition (gastroparesis, blockage, inflammatory bowel disease)Current diagnosis of or treatment for alcohol, opioid, or substance use disorder/dependenceNone of the above

Health Question 2: Do any of these apply to you?*

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

Yes

Have you had prior weight loss surgeries?*

Yes

Do you currently take any prescriptions?*

Yes

What is your average blood pressure range?*

<120/80 (Normal)

120-129/<80 (Elevated)

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

≥140/90 (High Stage 2)

What is your average resting heart rate?*

<60 beats per minute (Slow)

60-100 beats per minute (Normal)

101-110 beats per minute (Slightly Fast)

>110 beats per minute (Fast)

Lose weight confidently with safe, medically guided care—built for real life.